LCD : Percutaneous Transluminal Angioplasty in Renal Disease (L1413)

LCD for Percutaneous Transluminal Angioplasty in Renal Disease (L1413)

Contractor Information

Contractor Name ^{back to top}
BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)
Contractor Number ^{back to top}
00390
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}
L1413

LCD Title ^{back to top}
Percutaneous Transluminal Angioplasty in Renal Disease

Contractor's Determination Number ^{back to top}
1413

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2006 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.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations. Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction ^{back to top}
New Jersey Tennessee

Secondary Geographic Jurisdiction ^{back to top}
Alaska Alabama Arkansas Arizona California Colorado Connecticut Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi North Carolina North Dakota Nebraska New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Oversight Region ^{back to top}
Region IV


Original Determination Effective Date ^{back to top}
For services performed on or after 12/27/1996

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 12/07/2005

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Use of PTA (using the balloon technique) to dilate failing AV fistulas in the setting of renal dialysis, or to dilate stenotic renal arteries.

Coverage Topic ^{back to top}
Surgical Services

Coding Information

Bill Type Codes: ^{back
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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.

Revenue Codes: ^{back
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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.

032X	Radiology diagnostic-general classification
036X	Operating room services-general classification
049X	Ambulatory surgical care-general classification
075X	Gastro-intestinal services-general classification
076X	Treatment or observation room-general classification
094X	Other therapeutic services-general classification

CPT/HCPCS Codes ^{back
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35471	TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; RENAL OR VISCERAL ARTERY
75966	TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
76499	UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE

ICD-9 Codes that Support Medical Necessity ^{back
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440.1	ATHEROSCLEROSIS OF RENAL ARTERY
440.30	ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES
440.31	ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES
440.32	ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES
444.9	EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY
447.3	HYPERPLASIA OF RENAL ARTERY
996.1	MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.73	OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT

Diagnoses that Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back
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Diagnoses that DO NOT Support Medical Necessity ^{back
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General Information

Documentation Requirements ^{back
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Documentation should support medical necessity. If additional documentation is required, submit:

History and Physical
M.D. orders/progress notes
Procedure report
Itemization of charges

Appendices ^{back
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Utilization Guidelines ^{back
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Sources of Information and Basis for Decision ^{back
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Carrier Policy

Advisory Committee Meeting Notes ^{back
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This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period ^{back
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End Date of Comment Period ^{back
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Start Date of Notice Period ^{back
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11/27/1996

Revision History Number ^{back
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042-96h

Revision History Explanation ^{back
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03/01/2005 Added "3. If coding 35471 Transluminal balloon angioplasy, percutaneous; renal/visceral artery for angioplasty of celiac artery, remarks section must contain the phrase "Keyword:Celiac" on the first line of remarks" to Indications and Limitations of Coverage and/or Medical Necessity

HCPCS 75962 deleted from CPT/HCPCs Codes, Group 1

07/24/2002 Formatted

01/05/2001 codes updated by 2001 ICD-9 Code Book and 2001 CPT Code Book

This LCD was converted from an LMRP on 12/6/2005

5/24/2007 - Revenue Code 032X added

Last Reviewed On Date ^{back
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05/24/2007