Key facts for NCD 20.1
- Benefit category
- Inpatient Hospital Services, Physicians' Services
- Effective date
- This is a longstanding national coverage determination. The effective date of this version has not been posted.
- Transmittal
- n/a
- Versions published
- 1
- Manual chapter
- 20
- NCD Manual (Pub. 100-03)
TL;DR
NCD 20.1 sets Medicare's national policy for vertebral artery surgery under the benefit category "Inpatient Hospital Services, Physicians' Services", effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. These procedures can be medically reasonable and necessary, but only if each of the following conditions is met: It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
Obstructions which block the flow of blood through the vertebral artery can cause vertigo, visual or speech defects, ataxia, mental confusion, or stroke. These symptoms in patients result from reduction in blood flow to the brain and range from symptoms of transient basilar ischemia to mental deterioration or completed stroke.
Five types of surgical procedures are performed to relieve obstructions to vertebral artery blood flow. They are:
• Vertebral artery endarterectomy, a procedure which cleans out arteriosclerotic plaques which are inside the vertebral artery;
• Vertebral artery by-pass or resection with anastomosis or graft;
• Subclavian artery resection with or without endarterectomy;
• Removal of laterally located osteophytes anywhere in the C6(C7)-C2 course of the vertebral artery; and
• Arteriolysis which frees the artery from surrounding tissue, with or without arteriopexy (fixation of the vessel).
Indications and limitations of coverage
These procedures can be medically reasonable and necessary, but only if each of the following conditions is met:
• Symptoms of vertebral artery obstruction exist;
• Other causes have been considered and ruled out;
• There is radiographic evidence of a valid vertebral artery obstruction; and
• Contraindications to the procedure do not exist, such as coexistent obstructions of multiple cerebral vessels.
Angiograms documenting a valid obstruction should show not only the aortic arch with the vessels off the arch, but also show the vessels in the neck and head (providing biplane views of the carotid and vertebral vascular system). In addition, serial views are needed to diagnose "subclavian steal," the condition in which subclavian artery obstruction causes the symptoms of vertebral artery obstruction. Because the symptoms are not specific for vertebral artery obstruction, other causes must be considered. In addition to vertebral artery obstruction, the differential diagnosis should include various degenerative disorders of the brain, orthostatic hypotension, acoustic neuroma, labyrinthitis, diabetes mellitus and hypoglycemia related disorders.
Obstructions which can cause symptoms of blocked vertebral artery blood flow and which can be documented by an angiogram include:
• Intravascular obstructions - arteriosclerotic lesions within the vertebral artery or in other arteries.
• Extravascular obstructions.
• Bony tissue or osteophytes, located laterally in the C6(C7)-C2 cervical vertebral area course of the vertebral artery, most commonly at C5 -C6.
• Anatomical variations - Anomalous location of the origin of the vertebral artery, a congenital aberration, and tortuosity and kinks of the vertebral artery.
• Fibrous tissue - Tissue changed as a result of manipulation of the neck for neck pain or injury associated with hematoma; external bands, tendinous slings, and fibrous bands.
The most controversial obstructions include vertebral artery tortuosity and kinks and connective tissue along the course of the vertebral artery, and variously called external bands, tendinous slings and fibrous bands. In the absence of symptoms of vertebral artery obstruction, vascular surgeons feel such abnormalities are insignificant. Vascular surgery experts, however, agree that these abnormalities in very rare cases do cause symptoms of vertebral artery obstruction and do necessitate surgical correction.
Vertebral artery construction and vertebral artery surgery are phrases which most physicians interpret to include only surgical cleaning (endarterectomy) and bypass (resection) procedures. However, some physicians who use these terms mean all operative manipulations which remove vertebral artery blood flow obstructions. Also, some physicians use general terms of vascular surgery, such as endarterectomy when vertebral artery related surgery is performed. Use of the above terminology specifies neither the surgical procedure performed nor its relationship to the vertebral artery. Therefore, in developing claims for this type of procedure, require specific identification of the obstruction in question and the surgical procedure performed. Also, in view of the specific coverage criteria given, develop all claims for vertebral artery surgery on a case-by-case basis.
Make payment for a surgical procedure listed above if: (1) it is reasonable and necessary for the individual patient to have the surgery performed to remove or relieve an obstruction to vertebral artery flow, and (2) the four conditions noted are met.
In all other cases, these procedures cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act and are not reimbursable under the program.
Text reproduced from the CMS Medicare Coverage Database record for NCD 20.1 version 1. View the original on cms.gov.
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 20.1
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 20.1
What does NCD 20.1 cover?
These procedures can be medically reasonable and necessary, but only if each of the following conditions is met: The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 20.1 take effect?
The current version (1) is effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. This is the only published version.
Does a Local Coverage Determination override NCD 20.1?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.