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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