Download Carotid Artery Stent Criteria Form

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
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