Description
Lower extremity computed tomography angiography (CTA) is an effective, noninvasive and robust imaging modality that is used in the assessment of symptomatic lower extremity vascular disease. It has excellent spatial resolution and shows accurate details of peripheral vasculature. CTA is an effective alternative to catheter-based angiography and allows accurate planning of open surgical and endovascular interventions.

OVERVIEW:
Abdominal Arteries CTA — For imaging of the abdomen, pelvis and both legs (CTA aorto-iliofemoral runoff; abdominal aorta and bilateral iliofemoral lower extremity runoff) use CPT code 75635.

Peripheral Arterial Disease — CTA is used in the evaluation of patients with peripheral arterial disease. It can be used to evaluate the patency after revascularization procedures. It is the modality of choice in patients with intermittent claudication. A drawback is its hampered vessel assessment caused by the depiction of arterial wall calcifications, resulting in a decreased accuracy in severely calcified arteries.

Chronic Limb Threatening Ischemia — Assessment and promotion of blood flow through the calf arteries is very important in patients with chronic limb threatening ischemia. CT Angiography allows for visualization of pedal vessels.

Surgical or Percutaneous Revascularization — CTA is accurate in the detection of graft-related complications, including stenosis and aneurysmal changes. It can reveal both vascular and extravascular complications. 

CTA and screening for peripheral vascular disease: The USPSTF (U.S. Preventative Services Task Force) does not recommend routine screening for peripheral vascular disease in asymptomatic patients. High risk patients (e.g., diabetics) may be screened with ABI (ankle brachial index) and duplex ultrasound.

Policy
LOWER EXTREMITY CTA is considered MEDICALLY NECESSARY for the following indications:

Abdominal Arteries CTA (CT Angiography) (CPT Code 75635) includes run-off so this is never approved when one has been performed.

Peripheral Vascular Disease and Abdominal Arteries CTA (CT Angiography) (CPT Code 75635) has not been recently approved

• Critical Limb ischemia with ANY of the below with clinical signs of peripheral artery disease. Ultrasound imaging is not needed. If done and negative, it should still be approved due to high false negative rate (Shishehbor, 2016; Weiss, 2018):
  • Ischemic rest pain
  • Tissue loss
  • Gangrene
• Claudication with abnormal (ankle/brachial index, arterial Doppler) (Ahmed, 2017; Pollak, 2012, 2013)
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound (ankle/brachial index, arterial Doppler) (Rosyd, 2017)
• After stenting or surgery with signs of recurrent symptoms OR abnormal ankle/brachial index; abnormal or indeterminate arterial Doppler, OR pulse volume recording) (Pollak, 2012)

Popliteal Artery Entrapment Syndrome with abnormal arterial ultrasound (Williams, 2015)

Deep Venous Thrombosis with clinical suspicion of lower extremity DVT after abnormal or non-diagnostic ultrasound where a positive study would change management (Hanley, 2013; Karande, 2016; Katz, 2014)

Clinical suspicion of vascular disease with abnormal or indeterminate ultrasound or other imaging

• Tumor invasion (Kransdorf, 2018)
• Trauma (Wani, 2012) 
• Vasculitis  (Fonseca, 2017)
• Aneurysm (Verikokos, 2014)
• Stenosis/occlusions (Menke, 2010)

Hemodialysis Graft Dysfunction after Doppler ultrasound not adequate for treatment decisions (Murphy, 2017)

Vascular Malformation (Madani, 2015; Obara, 2019) -  
If MRA is contraindicated

• Non-diagnostic doppler ultrasound

Note: CTA useful in delineating high flow lesions such as an arteriovenous malformation.

Evaluation of traumatic injuries to the LE with clinical findings suggestive of arterial injury (Wani, 2012).

For assessment/evaluation of known vascular disease/condition

Pre-operative/procedural evaluation:

• Pre-operative evaluation for a planned surgery or procedure (Ahmed, 2017)

Post-operative/procedural evaluation: 

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (Conte, 2019; Cooper 2018). 

Special Circumstances (Weiss, 2017):  

• High suspicion of an acute arterial obstruction — Arteriography preferred (the gold standard).  
• Renal impairment
  • Not on dialysis
    • Mild to moderate, GFR 30 – 89 ml/min MRA can be done
    • Severe, GFR < 30 ml/min MRA without contrast
  • On dialysis
    • CTA with contrast can be done
• Doppler ultrasound can be useful in evaluating bypass grafts

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

References  

1. Aboyans V, Ricco JB, Bartelink M LEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries endorsed by: the European Stroke Organization (ESO) the Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018 Mar ; 39:763-816.  
2. Ahmed O, Hanley M, Bennett SJ, et al. American College of Radiology ACR Appropriateness Criteria ® - Vascular Claudication: Assessment for Revascularization. J Am Coll Radiol. 2017; 14(5 Suppl): S372-S379. https://acsearch.acr.org/docs/69411/Narrative/. 
3. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb=threatening ischemia. J Vasc Surg. 2019 Jun; 69(6S):3S-1255.e40. Epub 2019 May 28. 
4. Cooper K, Majdalany BS, Kalva SP, et al. ACR Appropriateness Criteria lower extremity arterial revascularization – post-therapy. J Am Coll Radiol. 2018 May; 15(5Suppl): S104-S115. 
5. Farber A. Chronic limb-threatening ischemia. N Engl J Med. 2018 Jul 12; 379(2):171-180. doi: 10.1056/NEJMcp1709326. 
6. Fonseka CL, Galappaththi SR, Abeyaratne D, et al. A Case of Polyarteritis Nodosa Presenting as Rapidly Progressing Intermittent Claudication of Right Leg. Case Reports in Medicine. 2017; 2017:4219718. 
7. Gerhard-Herman MD, Gornik HL. AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2017 Mar; 69(11). 
8. Hanley M, Donahue J, Rybicki FJ, et al. American College of Radiology ACR Appropriateness Criteria®  Clinical Condition: Suspected Lower-Extremity Deep Vein Thrombosis. https://acsearch.acr.org/docs/69416/Narrative/. Published 2013.  
9. Jin T, Wu G, Li X, et. al. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: Use of time-resolved 3D MR angiography at 3-T. Acta Radiol. 2018 May; 59(5):586-592.
10. Karande GY, Hedgire SS, Sanchez Y, et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc Diagn Ther. 2016; 6(6):493-507. http://doi.org/10.21037/cdt.2016.12.06.  
11. Katz DS, Fruauff K, Kranz A, et al. Imaging of deep venous thrombosis: A multimodality overview. Appl Radiol. March 5, 2014.  
12. Kransdorf MJ, Murphey MD, Wessell DE, et al. American College of Radiology ACR Appropriateness Criteria® - Soft Tissue Masses. https://acsearch.acr.org/docs/69434/Narrative/. Published 2017.  
13. Lopera JE, Trimmer CK, Josephs SG, et al. Multidetector CT angiography of infrainguinal arterial bypass. RadioGraphics. 2008; 28(2):529. doi: 10.1148/rg.282075032. https://pubs.rsna.org/doi/abs/10.1148/rg.282075032.  
14. Madani H, Farrant J, Chhaya N, et al. Peripheral limb vascular malformations: An update of appropriate imaging and treatment options of a challenging condition. Br J Radiol. 2015; 88(1047):20140406.  
15. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease.Ann Intern Med. 2010; 153(5):325-334. doi: 10.7326/0003-4819-153-5-201009070-00007.  
16. Met R, Bipat S, Legemate DA, et al. Diagnostic performance of computed tomography angiography in peripheral arterial disease: A systematic review and meta-analysis. JAMA. 2009; 301(4):415-424. doi: 10.1001/jama.301.4.415.  
17. Murphy EA, Ross RA, Jones RG, et al. Imaging in vascular access. Cardiovasc Eng Technol. 2017; 8(3):255–272.   
18. Obara P, McCool J, Kalva SP, et al. ACR Appropriateness Criteria clinically suspected vascular malformation of the extremities. J Am Coll Radiol. 2019 Nov; 16(11S):S340-S347.  
19. Pollak AW, Kramer CM. MRI in lower extremity peripheral arterial disease: Recent advancements. Curr Cardiovasc Imaging Rep. 2013 Feb 1; 6(1):55–60.  
20. Pollak AW, Norton P, Kramer CM. Multimodality imaging of lower extremity peripheral arterial disease: Current role and future directions. Circ Cardiovasc Imaging. 2012 Nov 1; 5(6):797–807.  
21. Rosyd FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017 Oct; 5(10):4206-4213.  
22. Shishehbor MH, White CJ, Gray BH, et al. Critical limb ischemia. Am Coll Cardiol. 2016; 68(18):2002–15.  
23. Tuite M, Kransdorf M, Beaman F, et al. American College of Radiology ACR Appropriateness Criteria® - Acute Trauma to the Knee. http://www.jacr.org/article/S1546-1440(15)00831- 5/fulltext. Published 2018.  
24. Verikokos C, Karaolanis G, Doulaptsis M, et al. Giant popliteal artery aneurysm: case report and review of the literature. Case Rep Vasc Med. 2014; 2014:780561.  
25. Wani ML, Ahangar AG, Ganie FA, et al. Vascular injuries:Trends in management. Trauma Mon. 2012; 17(2):266–269.  
26. Weiss C, Azene ER, Azene EM, et al. American College of Radiology (ACR). ACR Appropriateness Criteria® - Sudden Onset of Cold, Painful Leg. J Am Coll Radiol. 2017 May; 14(5Suppl):S307-S313.  

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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