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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Surgery
Policy Number:169
Effective Date: 03/30/2019
Original Policy Date:02/26/2019
Last Review Date:
Date Published to Web: 02/26/2019
Subject:
Placement of Iliac Vein Stent

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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Placement of a mesh tube into the iliac vein is intended to restore blood flow and maintain patency in a narrowed or collapsed iliac vein. Stent placement may be performed following an angioplasty or as an alternative to angioplasty.

According to UpToDate, May-Thurner syndrome (or iliac vein compression syndrome) is an anatomic variant resulting in the compression of the left common iliac vein between the overlying right common iliac artery and the underlying fifth lumbar vertebra. It is commonly seen in women between ages of 20 and 50. With partial venous obstruction, the condition can be asymptomatic. However, in patients with hemodynamically significant compression of the left common iliac vein, it has been associated with unprovoked left iliofemoral deep vein thrombosis (DVT) or chronic venous insufficiency. Episodes of DVT may be recurrent and/or poorly responsive to treatment with anticoagulation alone, and may require catheter-directed thrombolysis, venous angioplasty and/or intravascular stenting, especially in those with limb-threatening thrombosis.

Policy:
(NOTE: Horizon Blue Cross Blue Shield of New Jersey (“Horizon BCBSNJ”) has contracted with TurningPoint Healthcare Solutions, LLC (TurningPoint) to manage our Surgical and Implantable Device Management Program (“the Program”). TurningPoint will conduct Prior Authorization and Medical Necessity Determination reviews of certain cardiac services to be rendered July 15, 2019 and after to members enrolled in Horizon BCBSNJ fully insured plans.
    Beginning July 15, 2019, this policy’s criteria and guidelines will not apply to members included in the scope of the Program. This policy’s criteria and guidelines will only apply to members enrolled in plans that DO NOT participate in the Program.
      Visit our TurningPoint webpage for instructions on accessing the policy criteria and guidelines that TurningPoint will follow as they conduct PA/MND reviews as part of the Program. You may also call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time to request policy content.

      For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)


      1. Placement of an Iliac vein stent is considered medically necessary for members with moderate-severe May-Thurner syndrome (iliac vein compression syndrome):

        a. unilateral leg swelling and pain; AND
        b. demonstration of the venous stenotic lesion in an appropriate anatomic location with noninvasive venous imaging (computed tomography [CT] venography, magnetic resonance [MR] venography), or invasive venous imaging (catheter-based venography or intravascular ultrasound); AND
        c. skin changes (hyperpigmentation, venous eczema, lipodermatosclerosis, venous ulceration) associated with moderate-severe chronic venous insufficiency; AND
        d. history of deep vein thrombosis (DVT) or post thrombotic syndrome (PTS); AND
        e. member has failed at least 3 months of conservative management with compression stockings and leg elevation.

      2. All other indications for iliac vein stent placement are considered investigational.


      Medicare Coverage:
      Placement of a Iliac Vein Stent is covered when NCD 20.7 and LCD L35084 criteria are met.
        The placement of a stent in a vein for which there is no objective-related symptom or limitation of function is considered to be preventive and, therefore, not covered.
          Required Documentation:
          Pre- and post-deployment intervention images must be obtained and made available upon request. Documentation should include the nature of the obstruction, position of the device and, when appropriate, the effect of the device on target or nontarget vessels. Medical record documentation must list guide catheter used, as well as stent type, diameter and length.

          The following are considered not reasonable and necessary and therefore will be denied:
            Endovenous stents are contraindicated in patients with an existing contraindication to anticoagulation or thrombolytic therapy or those with an uncorrectable coagulopathy.
            Use of stents without U.S. FDA approval designation will be considered not medically necessary.
            Stenting of popliteal or tibial veins.
            Venous stenosis less than or equal to 50% of diameter of vein.

          National Coverage Determination (NCD) for Percutaneous Transluminal Angioplasty (PTA) (20.7). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.

          Local Coverage Determination (LCD): Non-Coronary Vascular Stents (L35084). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46

          Novitas has issued a Proposed Local Coverage Determination (LCD): Endovenous Stenting (DL37893) which is currently undergoing comment review and finalization. No final effective date has been issued. Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46

          Additionally, Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination, Future Local Coverage Determination (LCD): Endovenous Stenting (L37893), effective 5/20/19, with limited coverage for endovenous stents for patients with severely symptomatic venous obstructions. For additional information and eligibility, refer to LCD 37893 and associated Article Billing and Coding: Endovenous Stenting (A56414).

          Future Local Coverage Determination (LCD): Endovenous Stenting (L37893). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.

          Future Local Coverage Article: Billing and Coding: Endovenous Stenting (A56414). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.
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          Horizon BCBSNJ Medical Policy Development Process:

          This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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          Index:
          Placement of Iliac Vein Stent
          Iliac Vein Stent Placement
          Iliac Vein Stenting
          Stenting, Iliac Vein
          Stent Placement, Iliac Vein

          References:
          1. Mousa A. May-Thurner syndrome. In: UpToDate, Eidt JF (Ed), UpToDate, Waltham, MA. (Accessed on February 7, 2019.)

          2. Murphy EH, Black SA. Avoiding Misuse and Overuse of Iliac Vein Stenting for Chronic Venous Disease. Endovascular Today. 2018 July;17(7):74-76.

          3. Akers DL, Jr., Creado B, Hewitt RL. Iliac vein compression syndrome: Case report and review of the literature. J Vasc Surg. 1996;24:477-481.

          4. Kogel H. Regarding ’Iliac vein compression syndrome: Case report and review of the literature’. J Vasc Surg. 1997;26(4):721-722.

          5. Akesson H, Lindh M, Ivancev K, et al. Venous stents in chronic iliac vein occlusions. Eur J Vasc Endovasc Surg. 1997;13(3):334-336.

          6. Broholm R, Baekgaard N, Just SR, Jorgensen M. Endovascular treatment of chronic iliac vein obstruction in patients with venous claudication. Ugeskr Laeger. 2007 Apr 23 2007;169(17):1564-1568.

          7. Funatsu A, Shibata K, Yamamoto R, et al. [Initial and long term outcomes of stent implantation for iliac compression syndrome]. J Cardiol. 2007 Dec 2007;50(6):371-377.

          8. Mussa FF, Peden EK, Zhou W, Lin PH, Lumsden AB, Bush RL. Iliac vein stenting for chronic venous insufficiency. Tex Heart Inst J. 2007 2007;34(1):60-66.

          9. Neglen P. Chronic Venous Obstruction: Diagnostic Considerations and Therapeutic Role of Percutaneous Iliac Stenting. 2007.

          10. Lou WS, Gu JP, He X, et al. Endovascular treatment for iliac vein compression syndrome: A comparison between the presence and absence of secondary thrombosis. Korean J Radiol. 2009;10(2):135-143.

          11. Bi Y, Yu Z, Chen H, et al. Long-term outcome and quality of life in patients with iliac vein compression syndrome after endovascular treatment. Phlebology. 2019 Jan [Epub ahead of print].

          12. Jayarai A, Buck W, Knight A, et al. Impact of degree of stenosis in May-Thurner syndrome on iliac vein stenting. J Vasc Surg Venous Lymphat Disord. 2018 Dec [Epub ahead of print].

          13. Funatsu A, Anzai H, Komiyama K, et al. Stent implantation for May-Thurner syndrome with acute deep venous thrombosis: acute and long-term results from the ATOMIC (AcTive stenting for May-Thurner Iliac Compression syndrome) registry.Cardiovasc Interv Ther. 2018 Jun [Epub ahead of print].

          14. Sedhai TR, Golamari R, Salei A, et al. May-Thurner Syndrome. Am J Med Sci. 2018 May;355(5):510-514.

          Codes:
          (The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

          CPT*
            37238
            37239

          HCPCS

          * CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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          Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

          The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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