Is iliac revascularization with add-on procedures (37222 and 37223) medically necessary for a patient with peripheral vascular disease and lifestyle-limiting claudication?

Medical Necessity of Iliac Revascularization Add-On Procedures (37222,37223)

Yes, iliac revascularization with add-on procedures (CPT 37222 and 37223) is medically necessary for this patient with lifestyle-limiting claudication, documented hemodynamically significant iliac disease (ABIs 0.44-0.58), and persistent symptoms despite prior femoral endarterectomies. 1

Clinical Justification Based on Guidelines

Patient Meets All Criteria for Endovascular Intervention

This patient satisfies the Class I, Level A recommendation from the ACC/AHA for endovascular revascularization of aortoiliac disease 1:

• Lifestyle-limiting claudication: Patient reports right calf claudication that is "mildly lifestyle-limiting" and is "clearly now ready for treatment" after previously accepting status quo, indicating functional impairment affecting daily activities with his children 1, 2

• Hemodynamically significant disease documented: ABIs demonstrate moderately decreased perfusion bilaterally (right: 0.44-0.50, left: 0.58), well below the threshold of 0.90 that defines PAD, confirming hemodynamically significant occlusive disease 1

• Adequate trial of conservative management: Patient has undergone bilateral femoral endarterectomies, quit smoking, and reports "walking much better than ever," demonstrating compliance with risk factor modification 1, 2

• Patient has sufficient mobility to benefit: He is "keeping up with his kids and activity with them," confirming he has functional capacity to benefit from improved perfusion 1

Aortoiliac Disease Warrants Endovascular-First Strategy

The ACC/AHA guidelines provide a Class I, Level A recommendation specifically for endovascular procedures in patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease. 1 This is the strongest level of evidence-based recommendation available, indicating that endovascular treatment is definitively effective for this anatomic location and clinical presentation.

The 2017 ESC/ESVS guidelines similarly recommend an endovascular-first strategy for aortoiliac lesions, noting that short stenosis/occlusion (<5 cm) of iliac arteries achieves >90% patency over 5 years with low complication risk 1, 3. Even for longer or more complex iliac lesions, endovascular therapy remains appropriate as first-line treatment 1.

Why Iliac Lesions Are Prioritized Over Infrainguinal Disease

Patients with iliac lesions may be considered for revascularization without undergoing extensive medical therapy, unlike those with infrainguinal disease alone. 1 This is a critical distinction: the ACR Appropriateness Criteria specifically state that iliac artery disease can proceed directly to revascularization when lifestyle-limiting symptoms are present, whereas femoropopliteal disease typically requires more extensive conservative management first 1.

The planned procedure is an "iliac angiogram with the intent to treat his stenosis," which is appropriate given:

• Iliac interventions have superior long-term patency compared to femoropopliteal interventions 1
• The patient has already undergone bilateral femoral endarterectomies, suggesting the residual symptoms are likely from proximal (iliac) disease 1
• Non-palpable pedal pulses with easily palpable femoral pulses suggest inflow (iliac) disease as the limiting factor 1

Addressing the Mixed Symptomatology

Venous vs. Arterial Contribution

The provider notes uncertainty whether symptoms are from "venous insufficiency and arterial" disease, with "significant aching" from large varicose veins. However, the documented ABIs of 0.44-0.58 definitively establish hemodynamically significant arterial disease that warrants treatment regardless of coexisting venous pathology. 1

The ACC/AHA guidelines specify that revascularization is indicated for "hemodynamically significant" lesions with "reasonable likelihood of limiting perfusion to the distal limb" 1. ABIs below 0.60 meet this threshold unequivocally 1.

A common pitfall is delaying arterial revascularization in patients with mixed arterial-venous disease. The arterial component should be addressed first, as improved arterial inflow may reduce venous congestion and improve overall limb perfusion 1. The provider's plan to potentially treat "just the veins" first would be inappropriate given the severity of arterial disease documented.

Procedural Appropriateness: Add-On Codes 37222 and 37223

CPT 37222 (Iliac Revascularization Add-On)

This add-on code is appropriate when treating additional ipsilateral iliac vessels beyond the primary intervention (CPT 37220). Given the patient has bilateral disease and the plan is for "iliac angiogram with intent to treat," treating multiple iliac segments bilaterally would justify this add-on code 1.

CPT 37223 (Iliac Revascularization with Stent Add-On)

Primary stenting is indicated for iliac artery occlusions and is reasonable for stenoses, with Class I Level A evidence supporting stenting as effective primary therapy for common iliac artery stenosis and occlusions (TASC A and B lesions). 4, 5

The 2018 ACC/AHA/SCAI/SIR/SVM Appropriate Use Criteria specifically address iliac stenting, noting that iliac artery stenting provides similar durability to surgical revascularization but with much lower periprocedural risk 1. For iliac lesions, primary stenting achieves excellent long-term patency (>90% over 5 years for short lesions) 1, 3.

Evidence Hierarchy and Quality Assessment

The recommendations are based on:

• Class I, Level A evidence from the 2016 ACC/AHA guidelines for endovascular treatment of aortoiliac disease 1
• Multiple RCTs including the CLEVER trial, which specifically studied aortoiliac disease 1
• Consensus from multiple societies: ACC/AHA, ESC/ESVS, ACR, and SCAI/SIR all support endovascular-first approach for iliac disease 1

Important Caveat from Recent Evidence

The 2024 ACR update notes that the IRONIC trial showed revascularization lost its early benefit at 5 years, with no long-term improvement in quality of life or walking capacity compared with optimal medical therapy plus supervised exercise therapy alone 1. However, this trial included all anatomic segments, and the subgroup analysis from CLEVER specifically for aortoiliac disease showed sustained benefit at 18 months 1. The superior durability of iliac interventions compared to infrainguinal interventions makes this distinction clinically relevant 1.

Clinical Algorithm for Decision-Making

For this specific patient, proceed with iliac angiography and revascularization because:

1. ABIs <0.60 bilaterally = hemodynamically significant disease 1
2. Lifestyle-limiting symptoms persist despite prior surgical intervention and risk factor modification 1, 2
3. Aortoiliac anatomic location = Class I Level A indication for endovascular therapy 1
4. Patient has functional capacity to benefit (active with children) 1
5. Prior femoral endarterectomies suggest residual proximal disease as limiting factor 1

The procedures should NOT be performed if:

• Symptoms were purely venous without documented arterial insufficiency (not this case) 1
• Patient had asymptomatic disease discovered incidentally 1, 4
• ABIs were normal or near-normal (>0.90) at rest and post-exercise 1
• Patient had not attempted smoking cessation or risk factor modification (this patient has complied) 1, 2

Post-Procedure Management Requirements

Following successful revascularization, this patient must continue 2:

• Lifelong antiplatelet therapy (aspirin or clopidogrel) 1, 3
• Statin therapy regardless of lipid levels 1
• Continued risk factor modification including blood pressure and diabetes control 1
• Surveillance imaging at 1,6, and 12 months, then annually 3