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National Coverage Determination (NCD)

Vertebral Artery Surgery

20.1

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Tracking Information

Publication Number
100-3
Manual Section Number
20.1
Manual Section Title
Vertebral Artery Surgery
Version Number
1
Effective Date of this Version
This is a longstanding national coverage determination. The effective date of this version has not been posted.
Ending Effective Date of this Version
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Obstructions which block the flow of blood through the vertebral artery can cause vertigo, visual or speech defects, ataxia, mental confusion, or stroke. These symptoms in patients result from reduction in blood flow to the brain and range from symptoms of transient basilar ischemia to mental deterioration or completed stroke.

Five types of surgical procedures are performed to relieve obstructions to vertebral artery blood flow. They are:

  • Vertebral artery endarterectomy, a procedure which cleans out arteriosclerotic plaques which are inside the vertebral artery;
  • Vertebral artery by-pass or resection with anastomosis or graft;
  • Subclavian artery resection with or without endarterectomy;
  • Removal of laterally located osteophytes anywhere in the C6(C7)-C2 course of the vertebral artery; and
  • Arteriolysis which frees the artery from surrounding tissue, with or without arteriopexy (fixation of the vessel).
Indications and Limitations of Coverage

These procedures can be medically reasonable and necessary, but only if each of the following conditions is met:

  • Symptoms of vertebral artery obstruction exist;
  • Other causes have been considered and ruled out;
  • There is radiographic evidence of a valid vertebral artery obstruction; and
  • Contraindications to the procedure do not exist, such as coexistent obstructions of multiple cerebral vessels.

Angiograms documenting a valid obstruction should show not only the aortic arch with the vessels off the arch, but also show the vessels in the neck and head (providing biplane views of the carotid and vertebral vascular system). In addition, serial views are needed to diagnose "subclavian steal," the condition in which subclavian artery obstruction causes the symptoms of vertebral artery obstruction. Because the symptoms are not specific for vertebral artery obstruction, other causes must be considered. In addition to vertebral artery obstruction, the differential diagnosis should include various degenerative disorders of the brain, orthostatic hypotension, acoustic neuroma, labyrinthitis, diabetes mellitus and hypoglycemia related disorders.

Obstructions which can cause symptoms of blocked vertebral artery blood flow and which can be documented by an angiogram include:

  • Intravascular obstructions - arteriosclerotic lesions within the vertebral artery or in other arteries.
  • Extravascular obstructions.
  • Bony tissue or osteophytes, located laterally in the C6(C7)-C2 cervical vertebral area course of the vertebral artery, most commonly at C5 -C6.
  • Anatomical variations - Anomalous location of the origin of the vertebral artery, a congenital aberration, and tortuosity and kinks of the vertebral artery.
  • Fibrous tissue - Tissue changed as a result of manipulation of the neck for neck pain or injury associated with hematoma; external bands, tendinous slings, and fibrous bands.

The most controversial obstructions include vertebral artery tortuosity and kinks and connective tissue along the course of the vertebral artery, and variously called external bands, tendinous slings and fibrous bands. In the absence of symptoms of vertebral artery obstruction, vascular surgeons feel such abnormalities are insignificant. Vascular surgery experts, however, agree that these abnormalities in very rare cases do cause symptoms of vertebral artery obstruction and do necessitate surgical correction.

Vertebral artery construction and vertebral artery surgery are phrases which most physicians interpret to include only surgical cleaning (endarterectomy) and bypass (resection) procedures. However, some physicians who use these terms mean all operative manipulations which remove vertebral artery blood flow obstructions. Also, some physicians use general terms of vascular surgery, such as endarterectomy when vertebral artery related surgery is performed. Use of the above terminology specifies neither the surgical procedure performed nor its relationship to the vertebral artery. Therefore, in developing claims for this type of procedure, require specific identification of the obstruction in question and the surgical procedure performed. Also, in view of the specific coverage criteria given, develop all claims for vertebral artery surgery on a case-by-case basis.

Make payment for a surgical procedure listed above if: (1) it is reasonable and necessary for the individual patient to have the surgery performed to remove or relieve an obstruction to vertebral artery flow, and (2) the four conditions noted are met.

In all other cases, these procedures cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act and are not reimbursable under the program.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
Revision History
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Vertebral Artery Surgery 1 01/01/1966 - N/A You are here
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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