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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