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32485-Carotid Artery Stent Criteria Form_1_

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32485-Carotid Artery Stent Criteria Form_1_ Powered By Docstoc
					                                                                                             PLACE LABEL HERE
CAROTID ARTERY STENT
CRITERIA FORM
Date of procedure: ___________________
*Requirements
Type of Diagnostic Testing:            Duplex Doppler Ultrasound (degree of stenosis must be confirmed
                                        by Angiography at time of procedure)
                                       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                          PID Number

_____________ ______________            _______________________________
Date             Time                   Case Reviewer




*1-32485*                       FORM 1-32485 INITIATED 06/2012                                            Page 1 of 1

				
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