|
Diagnostic
arteriography is an invasive method of evaluating vascular disease. It
involves percutaneous passage of a catheter or needle into an artery under
fluoroscopic guidance, followed by injection of contrast material and
imaging of the vascular distribution in question using serial film or
digital imaging systems, under conscious sedation.
Renal and Iliac angiography is done via the femoral, brachial, or axillary
arterial approach into the abdominal aorta, and then into the region of the
renal and /or iliac arteries. The study generally consists of a flush
aortogram that visualizes the abdominal aorta, both renal arteries with
associated nephrograms, other visceral arteries, and the iliac arteries.
The test is done to evaluate the blood vessels in the kidney before
surgery, detect stenosis, blood clots, or aneurysm, help evaluate kidney
disease or failure, tumors, or kidney tissue function. It is also used to
evaluate donors and recipients before transplantation of a kidney.
Indications:
The following indications for aortography and renal and iliac arteriography
are adapted from the American College of Radiology Standard for the
Performance of Diagnostic Arteriography in Adults, effective January 1,
2003. RGBA will recognize these indications as reasonable and medically
necessary.
Aortography
1. Intrinsic abnormalities, including transection, dissection, aneurysm,
occlusive disease, aortitis, and congenital anomaly.
2. Evaluation of aorta and its branches prior to selective studies.
3. Prior to interventional procedures on the aorta.
Renal Arteriography
1. Renovascular occlusive disease (e.g., for hypertension or progressive
renal insufficiency)
2. Renovascular trauma
3. Primary vascular abnormalities, including aneurysms, vascular
malformations, and vasculitis
4. Renal tumors
5. Hematuria of unknown cause
6. Pre- and postoperative evaluations for renal transplantation
7. Prior to interventional procedures on the renal arteries.
Iliac Arteriography
1. Atherosclerotic aortoiliac disease
2. Gastrointestinal or genitourinary bleeding
3. Trauma
4. Primary vascular abnormalities, including aneurysms, vascular
malformations, and vasculitis
5. Male impotence caused by arterial occlusive disease
6. Pelvic tumors
7. Prior to interventional procedures
Renal and Iliac artery arteriography performed at time of cardiac
catheterization [G0275, G0278] will be considered reasonable by RGBA if
the patient has a clear indication of renal artery stenosis or the patient
undergoes stenting at a later date should significant renal artery stenosis
be discovered.
Clinical indications of the diagnosis of atherosclerotic renal artery
stenosis:
- Onset of hypertension after age 55
- Exacerbation of previously well controlled
hypertension
- Malignant hypertension
- Resistant hypertension
- Epigastric bruit (systolic/diastolic)
- Unexplained azotemia
- Azotemia while receiving ACEIs or
angiotensin receptor-blocking agents
- Atrophic kidney or discrepancy in size
between the two kidneys
- Recurrent congestive heart failure or
“flash” pulmonary edema
- Significant atherosclerosis elsewhere
associated with renal hypertension or renal disease
Diagnostic evaluation for renal hypertension is indicated for hypertension
that is refractory, of recent onset, or requires a sudden increase in
antihypertensive medication to control.
[Resistant or refractory hypertension generally refers to patients whose
blood pressure (BP) remains uncontrolled (often with systolic blood
pressure [SBP] of 160 mm Hg or more and diastolic blood pressure [DBP] of
100 mm Hg or more) despite sustained therapy with three or more
antihypertensive drugs including a diuretic.]
Limitations:
Aortography
Aortography has a limited role in the preoperative evaluation of abdominal
aortic aneurysms (AAA). Screening for AAA and monitoring the growth of
known aneurysms are most efficiently performed with Ultrasonography.
Computed Tomography (CT) is used as a screening test when ultrasound images
are suboptimal; as a diagnostic test when a hemodynamically stable,
ruptured AAA is suspected; and in the preoperative work-up for the repair
of AAAs. MRI combined with MRA provides excellent details for the
preoperative evaluation of AAAs.
Renal Arteriography
With modern noninvasive imaging techniques (Ultrasonography, Doppler
ultrasound, CT, MRI and MRA) the need for renal arteriography has been much
reduced. Therefore today renal arteriography is mainly used in conjunction
with lesions that can potentially be treated by interventional techniques
or to analyze renal vasculature preoperatively.
1. Angiography is rarely required to make diagnosis of renal artery
stenosis (RAS). Usually one or more of the non-invasive modalities
(Ultrasonography, MRI, CT, CTA) can accurately assess the renal arteries. A
prior non-invasive renal artery study should be positive or inconclusive
prior to performing renal arteriography. Exceptions to this rule may occur
in patients with fibromuscular dysplasia or renal artery aneurysms where
there may be branch involvement. Angiography therefore should be reserved
for patients in whom the diagnosis has been made and there are indications
to proceed with Percutaneous Transluminal Renal Angioplasty (PTRA) and
stent implantation.
2. Selective renal artery catheterization is not generally indicated in the
evaluation of renal artery stenosis (RAS) or renal hypertension.
The use of percutaneous closure devices with these procedures is not
separately payable.
Routine “drive-by angiography” at the time of cardiac catheterization
performed in the absence of accepted clinical indications that supports
medical necessity, as mentioned in this policy, will be denied.
Renal Angiography performed to diagnose RAS prior to a positive or
inconclusive non-invasive renal artery study will be denied, except for
patients with fibromuscular dysplasia or renal artery aneurysms where there
may be branch involvement.
Aortogram performed for preoperative evaluation of AAA must have
documentation to support why other non-invasive modalities mentioned in
this policy were impractical.
For outpatient settings other than CORFs, references to
"physicians" throughout this policy include non-physicians, such
as nurse practitioners, clinical nurse specialists and physician
assistants. Such non-physician practitioners may certify, order and
establish the plan of care for renal and iliac angiography and aortography
services only as authorized by State law. (See Sections 1861(s)(2)
and 1862(a)(14) of Title XVIII of the Social Security Act; 42 CFR, Sections
410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
|