Prediction of post-operative thrombosis in the internal jugular vein.Identification of the superficial temporal artery and vein in forehead flaps for facial reconstruction.

Guidance in redo ileocolic resection for Crohn's disease.

Evaluation of anastomotic stenosis of reconstructed superior mesenteric artery aneurysm.

Evaluation of anastomotic leakage in colorectal surgery.

Note: Intraoperative imaging of tissue perfusion is considered integral to the primary surgical procedure and is not separately reimbursed.Īetna considers near-infrared angiography with indocyanine green experimental and investigational for the evaluation of anastomotic perfusion after bowel resection for recto-sigmoid endometriosis.Īetna considers indocyanine green angiography experimental and investigational for evaluation of anastomotic perfusion in colorectal surgery, evaluation of the anastomotic leak/perfusion during or after esophagectomy, evaluation of residual parathyroid glands function and prediction of post-operative hypocalcemia risk after total thyroidectomy and all other indications because the safety and effectiveness of this approach has not been established.Īetna considers indocyanine green angiography experimental and investigational in the management of the following conditions (not an all-inclusive list) because it has not been demonstrated to add information that is useful in the management of these conditions: The physician's documentation should support the frequency and medical necessity of this procedure.Īetna considers the intra-operative use of indocyanine green angiography medically necessary for intracranial aneurysm surgery.Īetna considers near-infrared angiography with indocyanine green (e.g., Spy Elite System) medically necessary for breast reconstruction surgery.

Retinal pigment epithelium does not show subretinal neovascular membrane on current fluorescein angiography.

A fluorescein angiography need not have been previously done or

Presence of subretinal hemorrhage or hemorrhagic retinal pigment epithelium.

Evidence of ill-defined subretinal neovascular membrane or suspicious membrane on previous fluorescein angiography or.

Note: Documentation in the member's medical record should indicate one of the following:

Serous detachment of retinal pigment epithelium.Monitoring of foveo-macular vitelliform dystrophy (also known as Best disease) or.Hemorrhagic detachment of retinal pigment epithelium or.Exudative senile macular degeneration or.Acute posterior multi-focal placoid pigment epitheliopathy or.Aetna considers indocyanine green angiography medically necessary when it is used as an adjunct to fluorescein angiography in the diagnosis and management/treatment of any of the following conditions:

Stryker spy agent green