DRAFT Local Coverage Determination for Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency (DL32452)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402, 52280 |
Contractor Type Carrier - MAC - FI |
LCD Information
Document Information
DL32452 LCD Title Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency Contractor's Determination Number CV-041 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date Original Determination Ending Date Revision Effective Date Revision Ending Date |
CMS National Coverage Policy
Indications and Limitations of Coverage and/or Medical Necessity
Discussion
Multiple Sclerosis (MS)
MS is an autoimmune disease of the central nervous system. In MS, inflammation of nervous tissue causes the loss of myelin, a fatty material that acts as a protective insulation for the nerve fibers in the brain and spinal cord. This demyelination leaves multiple areas of hard scarred tissue (plaques) along the covering of the nerve cells. Another characteristic of MS is the destruction of axons, which are the long filaments that carry electric impulses away from a nerve cell. The demyelination and axon destruction disrupts the ability of the nerves to conduct electrical impulses to and from the brain, and produces the various symptoms.
Chronic cerebrospinal venous insufficiency (CCSVI)
Recent information suggests that obstruction to venous flow or inadequate venous valves in the great veins in the neck, thorax and abdomen may cause insufficient drainage and damaging backflow into the cerebral and spinal cord circulations.
Chronic cerebrospinal venous insufficiency (CCSVI) has been described as follows in multiple sclerosis (MS) patients. CCSVI is characterized by impaired brain venous drainage due to outflow obstruction in the extracranial venous system, mostly related to anomalies in the internal jugular and azygos veins. The current CCSVI diagnosis is based on Doppler sonography of extracranial and transcranial venous hemodynamics where there has been documentation of stenotic and occlusive lesions in the azygos and internal jugular veins in patients with MS. The literature is inconclusive on whether CCSVI is a clinically important factor in the development and/or progression of MS
Treatment of CCSVI with balloon angioplasty and or stent placement
Venous angioplasty (with or without stent placement) is currently under investigation as a method to improve blood flow in chronic cerebrospinal venous insufficiency (CCSVI). The hypothesis is that symptoms of MS might improve with this treatment. The literature however, is inconclusive on whether balloon angioplasty and/or stent placement are clinically effective in treating patients with MS.
Endovascular treatment for CCSVI is typically performed from common femoral vein access. Initially a venogram is performed so that images can be obtained. A small catheter is inserted and advanced into the right and left IJVs as well as the AZY vein. If the venogram indicates a vein is stenosed then angioplasty is performed. Another venogram is done post angioplasty to confirm that the stenosis was successfully corrected. If the venous angioplasty results in no change or worsening of the stenosis, then stent placement is considered. Individuals who receive a stent typically are placed on anticoagulants for at least three months.
Coverage
The evidence is inconclusive as to whether CCSVI impacts multiple sclerosis and therefore if treatment with angioplasty would impact the disease. Therefore, venous angioplasty (with or without stent placement) is considered investigational and not medically necessary for the treatment of multiple sclerosis and not covered by Medicare.
Multiple Sclerosis (MS)
MS is an autoimmune disease of the central nervous system. In MS, inflammation of nervous tissue causes the loss of myelin, a fatty material that acts as a protective insulation for the nerve fibers in the brain and spinal cord. This demyelination leaves multiple areas of hard scarred tissue (plaques) along the covering of the nerve cells. Another characteristic of MS is the destruction of axons, which are the long filaments that carry electric impulses away from a nerve cell. The demyelination and axon destruction disrupts the ability of the nerves to conduct electrical impulses to and from the brain, and produces the various symptoms.
Chronic cerebrospinal venous insufficiency (CCSVI)
Recent information suggests that obstruction to venous flow or inadequate venous valves in the great veins in the neck, thorax and abdomen may cause insufficient drainage and damaging backflow into the cerebral and spinal cord circulations.
Chronic cerebrospinal venous insufficiency (CCSVI) has been described as follows in multiple sclerosis (MS) patients. CCSVI is characterized by impaired brain venous drainage due to outflow obstruction in the extracranial venous system, mostly related to anomalies in the internal jugular and azygos veins. The current CCSVI diagnosis is based on Doppler sonography of extracranial and transcranial venous hemodynamics where there has been documentation of stenotic and occlusive lesions in the azygos and internal jugular veins in patients with MS. The literature is inconclusive on whether CCSVI is a clinically important factor in the development and/or progression of MS
Treatment of CCSVI with balloon angioplasty and or stent placement
Venous angioplasty (with or without stent placement) is currently under investigation as a method to improve blood flow in chronic cerebrospinal venous insufficiency (CCSVI). The hypothesis is that symptoms of MS might improve with this treatment. The literature however, is inconclusive on whether balloon angioplasty and/or stent placement are clinically effective in treating patients with MS.
Endovascular treatment for CCSVI is typically performed from common femoral vein access. Initially a venogram is performed so that images can be obtained. A small catheter is inserted and advanced into the right and left IJVs as well as the AZY vein. If the venogram indicates a vein is stenosed then angioplasty is performed. Another venogram is done post angioplasty to confirm that the stenosis was successfully corrected. If the venous angioplasty results in no change or worsening of the stenosis, then stent placement is considered. Individuals who receive a stent typically are placed on anticoagulants for at least three months.
Coverage
The evidence is inconclusive as to whether CCSVI impacts multiple sclerosis and therefore if treatment with angioplasty would impact the disease. Therefore, venous angioplasty (with or without stent placement) is considered investigational and not medically necessary for the treatment of multiple sclerosis and not covered by Medicare.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 018x | Hospital - Swing Beds |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 028x | Skilled Nursing - Swing Beds |
| 072x | Clinic - Hospital Based or Independent Renal Dialysis Center |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
| 0320 | Radiology - Diagnostic - General Classification |
| 0329 | Radiology - Diagnostic - Other Radiology - Diagnostic |
| 0360 | Operating Room Services - General Classification |
| 0361 | Operating Room Services - Minor Surgery |
| 0369 | Operating Room Services - Other OR Services |
| 0450 | Emergency Room - General Classification |
| 0490 | Ambulatory Surgical Care - General Classification |
| 0520 | Free-Standing Clinic - General Classification |
| 0521 | Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC |
| 0920 | Other Diagnostic Services - General Classification |
| 0929 | Other Diagnostic Services - Other Diagnostic Service |
| 0960 | Professional Fees - General Classification |
| 0981 | Professional Fees - Emergency Room Services |
| 0982 | Professional Fees - Outpatient Services |
| 0983 | Professional Fees - Clinic |
| 35460 | TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; VENOUS |
| 35476 | TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; VENOUS |
| 75978 | TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATION |
ICD-9 Codes that Support Medical Necessity
| XX000 | Not Applicable |
Diagnoses that Support Medical Necessity
NA
ICD-9 Codes that DO NOT Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity
| 340 | MULTIPLE SCLEROSIS |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
CPT codes 35460,
35476 and 35478 are used for many other conditions than the one
expressed in this policy
Appendices
Utilization Guidelines
Sources of Information and Basis for Decision
Suresh Vedantham,
MD, FSIR, James F. Benenati, MD, FSIR, Sanjoy Kundu, MD, FSIR, Carl M.
Black, MD, Kieran J. Murphy, MD, FSIR, and John F. Cardella, MD, FSIR;
Interventional Endovascular Management of Chronic Cerebrospinal Venous
Insufficiency in Patients with Multiple Sclerosis: A Position Statement
by the Society of Interventional Radiology, Endorsed by the Canadian
Interventional Radiology Association; J Vasc Interv Radiol 2010;
21:1335–1337
Zamboni P., Galeotti R., Menegatti E., Malagoni A.M., Mascoli F., Dall'Ara S., Bartolomei I., Salvi F.; Rationale and preliminary results of endovascular treatment of multiple sclerosis. the liberation procedure.
Zamboni P., Galeotti R., Menegatti E., et al.; Chronic cerebrospinal venous insufficiency
in patients with multiple sclerosis; J Neurol Neurosurg Psychiatry 2009 80: 392-399 originally published online December 5, 2008
Simka M, Kostecki J, Zaniewski M, Majewski E, Hartel M. Extracranial Doppler sonographic criteria of chronic cerebrospinal venous insufficiency in the patients with multiple sclerosis. Int Angiol 2010; 29:109–114
Al-Omari MH, Rousan LA.; Internal jugular vein morphology and hemodynamics in patients with multiple sclerosis.; Int Angiol 2010; 29:115–120.
Zamboni P., Galeotti R., Menegatti E., Malagoni A.M., Mascoli F., Dall'Ara S., Bartolomei I., Salvi F.; Rationale and preliminary results of endovascular treatment of multiple sclerosis. the liberation procedure.
Zamboni P., Galeotti R., Menegatti E., et al.; Chronic cerebrospinal venous insufficiency
in patients with multiple sclerosis; J Neurol Neurosurg Psychiatry 2009 80: 392-399 originally published online December 5, 2008
Simka M, Kostecki J, Zaniewski M, Majewski E, Hartel M. Extracranial Doppler sonographic criteria of chronic cerebrospinal venous insufficiency in the patients with multiple sclerosis. Int Angiol 2010; 29:109–114
Al-Omari MH, Rousan LA.; Internal jugular vein morphology and hemodynamics in patients with multiple sclerosis.; Int Angiol 2010; 29:115–120.
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 01/27/2012
Illinois 01/25/2012
Michigan 02/01/2012
Minnesota 02/02/2012
J5: Iowa, Kansas, Missouri, Nebraska 02/02/2012
Open LCD meeting Date:
01/12/2012
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Wisconsin 01/27/2012
Illinois 01/25/2012
Michigan 02/01/2012
Minnesota 02/02/2012
J5: Iowa, Kansas, Missouri, Nebraska 02/02/2012
Open LCD meeting Date:
01/12/2012
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Start Date of Comment Period
02/02/2012
End Date of Comment Period
03/14/2012
Start Date of Notice Period
Revision History Number
Reason for Change
This LCD has no Related Documents.
LCD Attachments
There are no attachments for this LCD.
Draft Contact
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.
Page Last Updated: Thursday, 05-Jan-2012 08:08:46 CST
Home |
Web Help |
Feedback |
About WPS
© Wisconsin Physicians Service Insurance Corporation | All Rights Reserved
Privacy Statement | Legal Disclaimer
