Endovascular therapy with a retrievable stent is medically necessary for acute ischemic stroke with occlusion of the middle cerebral artery trunk or its branches, or the internal carotid artery, when salvageable tissue is shown on imaging and retrieval is performed within 12 hours after stroke onset. Intra-arterial infusion of spasmolytics such as papaverine, or calcium-channel blockers such as nicardipine, into intracranial arteries is medically necessary only for medically refractory symptomatic delayed cerebral ischemia (cerebral vasospasm) after aneurysmal subarachnoid hemorrhage, and is experimental, investigational, or unproven for all other indications. Acute stenting with concomitant tirofiban, cerebrolysin, defibrinogen therapy, erythropoietin, hypothermia, transcranial ultrasound such as the CLOTBUST-HF device, sphenopalatine ganglion stimulation, statins, and vagus nerve stimulation for myocardial atrophy after AIS are experimental, investigational, or unproven, along with several other listed therapies.
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01Check current applicability before billing, because the next scheduled review of this policy is 09/10/2026.
02Bill CPT 37184, 37185, or 61645 for endovascular treatment only when the selection criteria are met: anterior circulation occlusion, salvageable tissue on imaging, and retrieval performed within 12 hours after stroke onset.
03The covered ICD-10 codes when the criteria are met are I63.00 through I63.9 for cerebral infarction and I67.82 or I67.841 through I67.848 for medically refractory symptomatic delayed cerebral ischemia.
04CPT codes 61885, 61886, 61888, 64568, 64569, 38206, 38232, and 38241 are listed as not covered for the indications in the policy, and HCPCS codes J3246 and J2265 are listed as not covered for the indications in the policy.
Summaries are AI-assisted. Always confirm against the original payer notice.
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