The use of endoprostheses approved by the U.S. Food and Drug Administration (FDA) as a treatment of abdominal aortic aneurysms (AAAs) may be considered medically necessary in any of the following clinical situations:
an aneurysmal diameter greater than 5.0 cm
an aneurysmal diameter of 4 to 5.0 cm that has increased in size by 0.5 cm in the last 6 months
an aneurysmal diameter that measures twice the size of the normal infrarenal aorta
a ruptured AAA (see Policy Guidelines section).
The use of endoprostheses approved by the FDA as a treatment of AAAs is considered investigational when the above criteria are not met, including but not limited to the following clinical situations:
Treatment of smaller aneurysms that do not meet the current recommended threshold for surgery
Treatment of aneurysms that do meet the recommended threshold for surgery in patients who are ineligible for open repair due to physical limitations or other factors.
