BCC’s Prior Authorization Update for Endovascular Treatment for Intermittent Claudication
Endovascular revascularization for treatment of intermittent claudication is clinically proven and therefore medically necessary for members with peripheral artery disease when all of the following criteria are met (Conte, 2015; Gerhard-Herman, 2017):
- Significant functional or lifestyle-limiting disability.
- Hemodynamically significant aortoiliac occlusive disease, femoropopliteal disease, or multivessel tibial disease with a stenosis of at least 50%.
- Failure of at least 12 weeks of guideline-directed pharmacotherapy or exercise therapy, or both, to control symptoms.
- Documented discontinuation of smoking and other tobacco use.
- There is a reasonable likelihood of symptomatic improvement with endovascular treatment.
- The benefits of treatment outweigh the potential risks.
Prior authorization must be obtained before performing endovascular revascularization when the above criteria are present.
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