Thrombectomy Systems (CPB 0568, reviewed 2025-08-26)
Aetna considers the AngioJet Rheolytic Thrombectomy System medically necessary for removing fresh blood clots from arteriovenous fistulas used for hemodialysis, from coronary arteries or coronary bypass grafts at least 2.0 mm in diameter before angioplasty or stent placement, from infra-inguinal peripheral arteries at least 2.0 mm in diameter, and in individuals with lower extremity deep vein thrombosis who have failed pharmacologic thrombolysis or in whom pharmacologic thrombolysis is contraindicated. Thrombectomy systems are considered experimental, investigational or unproven for acute aortic occlusion, acute renal artery thrombosis, cerebral venous sinus thrombosis, inferior vena cava filter-related thrombosis, May-Thurner syndrome-related deep venous thrombosis, pulmonary embolism, and thrombosis of the native aortic valve and of the left ventricular assist device in heart failure. The ClotHunter for lower extremity deep vein thrombosis and mechanical thrombectomy or thrombo-aspiration for acute ilio-femoral deep vein thrombosis are also considered experimental, investigational or unproven.