Intracranial stent placement may be considered medically necessary as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment is not appropriate and standard endovascular techniques do not allow for complete isolation of the aneurysm, eg, wide-neck aneurysm (≥4 mm) or a sack-to-neck ratio less than 2:1.
Intracranial flow-diverting stents with U.S. Food and Drug Administration (FDA) approval for the treatment of intracranial aneurysms may be considered medically necessary as part of the endovascular treatment of intracranial aneurysms that meet anatomic criteria (see Policy Guidelines section) and are not amenable to surgical treatment or standard endovascular therapy.
Intracranial stent placement is considered investigational in the treatment of intracranial aneurysms except as noted above.
Intracranial percutaneous transluminal angioplasty with or without stenting is considered investigational in the treatment of atherosclerotic cerebrovascular disease.
The use of endovascular mechanical embolectomy using a device with FDA approval for the treatment of acute ischemic stroke may be considered medically necessary as part of the treatment of acute ischemic stroke for patients who meet all of the following criteria:
Have a demonstrated occlusion within the proximal intracranial anterior circulation (intracranial internal carotid artery, or M1 or M2 segments of the middle cerebral artery, or A1 or A2 segments of the anterior cerebral artery); AND
Can receive endovascular mechanical embolectomy within 12 hours of symptom onset OR within 24 hours of symptom onset if there is evidence of a mismatch between specific clinical and imaging criteria (see Policy Guidelines); AND
Have evidence of substantial and clinically significant neurologic deficits (see Policy Guidelines section); AND
Have evidence of salvageable brain tissue in the affected vascular territory (see Policy Guidelines section); AND
Have no evidence of intracranial hemorrhage or arterial dissection on computed tomography or magnetic resonance imaging.
Endovascular interventions are considered investigational for the treatment of acute ischemic stroke when the above criteria are not met.