January 16th, 2018
The following information is according to Novitas Solutions L35084.
Renal artery: Stenting may be indicated for renal artery stenosis causing renovascular hypertension (see below) or renal insufficiency as well as post-transplant renal artery stenosis, arterial aneurysm or dissection. Renal artery angioplasty with or without stenting is covered for renal artery stenosis manifested by at least one of the following conditions:
- Recurrent (“flash”) pulmonary edema without cardiac or other obvious etiology and with renal artery stenosis of greater than or equal to 60 percent of the vessel diameter.
- Rapidly progressive renal insufficiency or acute renal failure in patients at risk for renal artery stenosis when another cause for renal deterioration has been sought and is not present, and with renal artery stenosis of greater than or equal to 75 percent of the vessel diameter and with one of the following in addition to progressive renal insufficiency:
- Coexisting diffuse atherosclerotic vascular disease.
- Acute renal failure precipitated by antihypertensive therapy, particularly angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.
- Renal artery dissection.
- Renal artery aneurysm.
- Renal artery stenosis greater than or equal to 50 percent in a transplanted kidney.
Renovascular hypertension (all criteria must be met):
- Hypertension is not controlled (lowest blood pressure recorded by a physician of 160 mm Hg systolic or 90 mm Hg diastolic or 160 mm Hg in patients with isolated systolic hypertension despite documented adherence to treatment with maximum accepted doses of three or more antihypertensive medications.
- Renal artery stenosis demonstrated by renal arteriography with luminal cross-sectional area reduction of 75 percent or vessel diameter narrowing greater than 50 percent. Stenting of renal artery stenosis of less than 75 percent reduction of luminal cross-sectional area/50 percent reduction of vessel diameter may be indicated when renal vein renin studies clearly indicate renal artery stenosis to be the cause of the elevated blood pressure.
- I70.1* - Atherosclerosis of renal artery
- I72.2 - Aneurysm of renal artery
- I75.81 - Atheroembolism of kidney
- I77.3* - Arterial fibromuscular dysplasia
- I77.73 - Dissection of renal artery
- Q27.1 - Congenital renal artery stenosis
- Q27.2 - Other congenital malformations of renal artery
- Q27.34 - Arteriovenous malformation of renal vessel
- Kidney transplant
- Hypertensive chronic kidney disease
- Hypertensive heart and chronic kidney disease
- I13.0 - with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
- I13.10 - without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
- I13.11 - without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
- I13.2 - with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
- I15.0 - Renovascular hypertension
- I15.1 - Hypertension secondary to other renal disorders
- J81.0 - Acute pulmonary edema
- N17.8 - Other acute kidney failure
- N17.9 - Acute kidney failure, unspecified
- N26.2 - Page kidney