Cerebrovascular Angioplasty, Stenting, and Select Surgical Procedures (CPB 0276, reviewed 2026-06-05)

By 2026-06-05: Billing team must update claims processing rules and prior authorization workflows to enforce Aetna's updated medical necessity criteria for cerebrovascular procedures (CPB 0276). Specifically: (1) For carotid artery stenting (CPT 37215, 37216, 37217, 37218), require documentation of symptomatic stenosis ≥50% OR asymptomatic ≥70%, completed duplex ultrasound, CTA/MRA confirmation, and neurologist assessment with NIHSS certification before and after procedure; (2) Update prior auth templates to verify discussion of all treatment options (CEA, TFCAS, TCAR, medical therapy) with documented risks/benefits; (3) Flag claims for carotid revascularization in patients with modified Rankin scale ≥3 (disabling stroke) for denial per policy; (4) Deny all claims for extracranial vertebral artery stenting for asymptomatic stenosis (0075T, 0076T) as experimental/investigational; (5) Deny intracranial angioplasty/stenting (CPT 61630, 61635, 61640, 61641, 61642) when coded for prophylaxis or atherosclerotic stenosis without dual diagnosis of subarachnoid hemorrhage AND ischemia; (6) Update encounter forms and provider alerts to highlight documentation requirements; (7) Providers and billing staff should reference related policies CPB 0621 (Drug-Eluting Stents), CPB 0785 (Endovascular Arterial and Venous Stent Procedures), CPB 0789 (Acute Ischemic Stroke Treatments). Failure to enforce these criteria will result in claim denials and potential rework.