About this policy
CMS National Coverage Determination | ncd_id=54 | manual_section=20.2 | coverage_level_code=2 | national_coverage_type=True | under_review=False | lab_ncd=False
Coverage indications
Extracranial-Intracranial (EC-IC) arterial bypass surgery is not a covered procedure when it is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries, which includes the treatment or prevention of strokes. The premise that this procedure which bypasses narrowed arterial segments improves the blood supply to the brain and reduces the risk of having a stroke has not been demonstrated to be any more effective than no surgical intervention. Accordingly, EC-IC arterial bypass surgery is not considered reasonable and necessary within the meaning of §1862(a)(1) of the Act when it is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries.
Documentation requirements
Revision History: 06/1991 - Renamed to reflect current terminology for procedure and revised to provide that Medicare coverage no longer allowed when EC-IC surgery performed to treat ischemic cerebrovascular disease of carotid or middle cerebral arteries. Effective date 03/27/1991. (TN 47) Benefit Categories: 35 - Inpatient Hospital Services; 52 - Physicians' Services Transmittal: transmittal_number=47 | transmittal_issue_date=1991-06-01
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
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