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PLACE LABEL HERE CAROTID ARTERY STENT CRITERIA FORM Date of procedure: ___________________ *Requirements Duplex Doppler Ultrasound (degree of stenosis must be confirmed by Angiography at time of procedure) Type of Diagnostic Testing: Angiography Percentage of Stenosis ________ % (Must be equal to or greater than 70% to qualify for coverage) Approved Stent with Embolic Protection: Acculink (non drug-eluting) Xact (non drug-eluting) Precise (non drug-eluting) **High Risk for CEA Criteria: Congestive Heart Failure (CHF) class III/IV Age equal to or greater than 80 Renal Failure: end stage on dialysis Common Carotid Artery Lesion(s) below clavicle Severe pulmonary disease Left Ventricular Ejection Fraction (LVEF) less than 30% Unstable angina High Cervical Internal Carotid Artery lesion(s) Contralateral carotid occlusion Recent Myocardial Infarction (MI) Previous CEA with recurrent stenosis Tracheostomy Prior radiation treatment to the neck Contralateral laryngeal nerve palsy Other: ________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ **If the patient does not have one of these conditions, an ABN should be appropriately executed. If the patient has other significant comorbid conditions that, in the opinion of a surgeon, would put the patient at high risk for CEA, those conditions must be documented clearly. Symptoms of Carotid Artery Stenosis: Carotid Transient Ischemic Attack (TIA) Focal cerebral ischemia producing a nondisabling stroke (modified Rankin scale less than 3 with symptoms for 24 hrs or more) Transient monocular blindness (amaurosis fugax) *If any one area is not marked, then the CAS will not be covered by Medicare and an ABN should be appropriately executed. _____________ ______________ Date Time _______________________________ Physician Signature _____________ ______________ Date Time _______________________________ Case Reviewer *1-32485* FORM 1-32485 INITIATED 06/2012 ___________ PID Number Page 1 of 1