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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