Chapter 4
Section 10.1
Transjugular Intrahepatic Portosystemic
Shunt (TIPS)
Issue Date: May
7, 1999
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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