About this policy
Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. Type: Active LCD
Coverage indications
CTP (using automated post-processing software algorithmic analysis) is medically reasonable and necessary in patients with small acute ischemic stroke (AIS) caused by a unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers; CTP can be used to aid in selection for endovascular mechanical thrombectomy (EVT) if one of the following other conditions is fulfilled: Treatment (femoral puncture) can be started within 6-24 hours of the time last known to be at neurologic baseline and who meet the pre-CTP inclusion/exclusion criteria* as defined by the DAWN trial (1), or Treatment (femoral puncture) can be started within 6-16 hours of the time last known to be at neurologic baseline and who meet the pre-CTP inclusion/exclusion criteria* as defined by the DEFUSE 3 trial (2) *excluding criteria purely related to study mechanics (e.g., able to return for protocol required follow-up visits, etc.).
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.
| Code | Code system | Status in this policy |
|---|---|---|
| 70472 | CPT | Covered |
| 70473 | CPT | Covered |
| G43.401 | ICD10CM | Covered |
| G43.409 | ICD10CM | Covered |
| G43.411 | ICD10CM | Covered |
| G43.419 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |