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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 10.1
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Issue Date:  May 7, 1999
Authority:  32 CFR 199.4(c)(2) and (c)(3)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODES
37140 - 37181, 37205, 49425
2.0  DESCRIPTION
TIPS is an invasive radiological procedure performed percutaneously through the jugular vein and involves the creation of an intrahepatic shunt between the hepatic vein and portal vein.
3.0  POLICY
TIPS is covered for the following indications. The list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective and comparable or superior to standard care (proven).
3.1  Therapy of acute or recurrent esophageal variceal bleeding which is not controlled by or is unresponsive to standard treatment such as endoscopic therapy, pharmacological therapy or surgical shunt.
3.2  Patients with irreversible hepatic disease who are candidates for liver transplantation and require control of esophageal variceal bleeding.
3.3  For the treatment of patients with refractory ascites.
4.0  EFFECTIVE DATES
4.1  September 29, 1995, for acute or recurrent esophageal varical bleeding.
4.2  June 8, 2000, for refractory ascites.
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