Diagnostic Abdominal Aortography and Renal Angiography-Local Coverage Determination

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity
1. The indications for renal arteriography adapted from the American College of Radiology (1999) include the following:

Severe and/or difficult to control renal vascular hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

Recent onset of severe or relatively severe hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

Sudden need to increase medications to control hypertension (uncontrolled hypertension with a systolic blood pressure greater than or equal to 160 mmHg or a diastolic blood pressure greater than or equal to 100 mmHg on at least two anti-hypertensive drugs);

Deterioration of renal function; and

Abnormal radionuclide renogram.

2. Renal arteriography is indicated for those patients with recurrent acute pulmonary edema who are status post-op renal transplantation or patients with recurrent (flash) pulmonary edema.

3. Renal arteriography is indicated for those patients having primary or secondary, benign or malignant neoplasm of the kidney.

4. Abdominal aortography and/or renal arteriography may be indicated for those patients with known/suspected aneurysm, dissection, or trauma involving the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

5. Abdominal aortography and/or renal arteriography may be indicated for those patients having mid-abdominal bruits or known/suspected vascular diseases of the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

6. In addition to the initial procedure, an appropriate frequency of repeat procedures can be allowed as long as medical necessity is clearly
established and documented, e.g., there is a reason for performing the procedure. It is expected that important diagnostic information will be obtained from the angiography, which will assist in the patient’s management and treatment. Repeat angiography can be acceptable if there is an appearance of new and incapacitating symptoms or an exacerbation or chronic symptoms, even following an interventional procedure, such as PTA and/or renal stenting.

Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

a. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, or

b. A prior study is available, but as documented in the medical record:

The patient’s condition with respect to the clinical indication has changed since the prior study; OR

There is inadequate visualization of the anatomy and/or pathology; OR

There is a clinical change during the procedure that requires new evaluation outside the target area of intervention

7. Appropriate non-invasive tests should be performed prior to the repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient has not responded to an adequate trial of medical management or is deemed unstable and in need of some type of surgical intervention. In all instances, documentation must be submitted upon request justifying the repeat procedure and establishing medical necessity.

8. These services may be performed in a hospital, a hospital outpatient area, or an approved independent catheterization laboratory.

9. Aortography (from ACR Guideline: Quality Improvement Guidelines for Diagnostic Arteriography, September 2003):

Intrinsic abnormalities, including transection, dissection, aneurysm, occlusive disease, aortitis, and congenital anomaly;

Evaluation of aorta and its branches prior to selective catheterization and performance of therapeutic interventional procedures; or

Before interventional procedures.

10. Renal Arteriography (from ACR guideline: Practice Guideline for the Performance of Diagnostic Arteriography in Adults, Res. 25, Amended 2004):

Renovascular occlusive disease (e.g., for hypertension or progressive
renal insufficiency);

Renal vascular trauma;

Primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis;

Renal tumors;

Hematuria of unknown cause (following inconclusive noninvasive testing [not included in ACR]);

Pre- and postoperative evaluation for renal transplantation; or

Evaluation prior to performance of therapeutic interventional procedures.

CMS issued HCPCS code G0278 for femoral and/or iliac angiography when done at the time of coronary angiography. Medicare would not expect to see a high percentage of femoral and/or iliac angiography done at the same time of coronary studies and such billing could be subject to review.

CMS proposes 2016 payment and policy updates for Medicare Health and Drug Plans

Proposed policies continue Secretary’s initiative tying Medicare payments to value and maintain stability of Medicare Advantage program

The Centers for Medicare and Medicaid Services (CMS) today released proposed changes for the coming year for the Medicare Advantage (MA) and Part D Prescription Drug Programs that will advance Health and Human Services Secretary Sylvia M. Burwell’s vision of building a better, smarter health care system and moving the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.

“The proposed rates will enhance the stability of Medicare Advantage program and minimize disruption to seniors and care providers," said Andy Slavitt, CMS Principal Deputy Administrator. "The policies in the Notice and Call Letter will continue the movement to reward providers of high quality, consumer-friendly care for the Medicare Advantage and Part D programs."

The Medicare Advantage and the Part D Prescription Drug programs’ enrollments and quality continue to grow and improve since the Affordable Care Act. Medicare Advantage has reached record high enrollment each year since 2010, a trend continuing in 2015 with a total increase of more than 40 percent since passage of the Affordable Care Act, and premiums have fallen by nearly 6 percent from 2010 to 2015. And, more than 90 percent of Medicare beneficiaries have access to a $0 premium Medicare Advantage plan.

This continued popularity of the program reflects a clear signal that Medicare Advantage and the Prescription Drug Program are attractive to health plans and beneficiaries alike. Today’s proposal will continue this trend by providing fair payments to plans, rewarding high-quality care, and spending our health care dollars wisely. We believe these policies will minimize disruption and continue our commitment to high-quality plans, and create a stable and consistent policy environment.

The proposed changes reflect the commitment to a Medicare program that delivers better care, spends health care dollars more wisely and results in healthier people. In 2015, CMS estimates that 60 percent of Medicare Advantage enrollees will be in 4 or 5 star plans – an increase of 43 percent since 2009. In the Draft Call Letter, CMS is proposing to continue to refine the star rating system to so as to continue to encourage improved quality, including a proposal to modify the system to ensure plans are not unfairly penalized for enrolling dual eligible or low-income beneficiaries. In addition, the proposal enhances the value of in-home assessments so they are used to support care planning and care coordination and improve enrollee health outcomes.

The Advance Rate Notice proposes changes in payments that will affect plans differently depending on a variety of factors. On average, when combined with expected growth in plan risk scores due to coding, the expected revenue change would be positive growth of 1.05 percent. Plans that have shown quality improvement and have demonstrated a focus on customer satisfaction would see additional growth. Plan payment levels will continue to be somewhat higher than the equivalent payments in fee for service.

Finally, the proposed policies promise to provide enrollees with greater information to make informed decisions about their care and their coverage. The 2016 Draft Call Letter proposes steps to ensure that plans maintain accurate provider directories and make those directories widely available, helping enrollees better understand the providers available to them. In addition, CMS proposes to work with Part D sponsors that offer limited access to preferred cost sharing pharmacies in their networks to ensure all beneficiaries have access to affordable coverage.