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Endovascular aneurysm repair

An overview of market access challenges for endovascular aneurysm repair (EVAR) in European countries


Procedure coding

Typically, procedure coding is well-established for EVAR in European countries. 

Procedure codes for EVAR may differ depending on the anatomical part of the aorta (e.g., thoracic aorta, abdominal aorta, etc.) and the type of graft (e.g., number of fenestrations, branches, etc.). 

For example, in Germany, OPS procedure coding for endovascular implantation of stent grafts in the abdominal aorta distinguishes between stent graft without opening (code 5-38a.c0), stent graft with one opening (code 5-38a.c1), stent graft with two openings (code 5-38a.c2) or stent graft with three or more openings (code 5-38a.c3).


Payment mechanism

The payment model varies by country.

In many EU countries, the EVAR is reimbursed via the diagnosis-related group (DRG) mechanism. 

In some countries (e.g., France and Germany), devices for EVAR attract additional (top-up) reimbursement, which is paid in addition to the DRG tariff. 

For example, in Germany, several add-on ZE categories exist depending on the type of stent graft (depending on the number of fenestrations), with pricing mainly determined locally.

Add-on reimbursement can be either generic (at the class level, as in Germany) or brand-specific (with specific LPPR codes for individual brands in France). 


Policy considerations

Due to high costs, EVAR can be subject to specific policies from payers or national decision-makers in the countries where such frameworks exist. 

For example, in England, the national payer, NHS England, developed the clinical commissioning policy “Use of Complex Endovascular Stent Grafts in the Management of Abdominal Aortic Aneurysm”, in which NHS England outlined categories of patients eligible for elective EVAR surgery. 


Health technology assessment

Due to established reimbursement in European countries, EVAR rarely becomes a subject of HTA. 


Future challenges 

EVAR has established reimbursement and funding in most of the European countries. New health technology assessments are unlikely to be relevant. 

Novel devices for EVAR with unique designs and properties or different cost profiles might need to develop specific procedure codes and adjust payment mechanisms to leverage their unique technology or cost profile fully. 

An important topic for EVAR is the establishment of reimbursement and funding for devices used in secondary procedures in patients with an existing EVAR.

MTRC has experience with more than 3 projects related to EVAR in Europe

News and insights

New procedure and diagnostic codes added to the private reimbursement schedule in England

In April 2023, the Clinical Coding and Schedule Development (CCSD) working group, which develops and maintains procedural and diagnostics nomenclatures for private payers in England, published Bulletins 189 and 085 with changes to be implemented no later than June 15, 2023. Eighteen new procedure codes (concerning cardiovascular, endocrine, endoscopy, gastrointestinal, interventional radiology, neuromodulation, peripheral vascular, robotic surgery, men's health, and general surgery fields) and eight new diagnostic codes were introduced.

The 2023 list of medical technologies approved for innovation funding (NUB) released in Germany

On January 30, 2023, the Institute for the Hospital Remuneration System (InEK) published the list of the requests for innovation funding (NUB) that were submitted by the hospitals in 2022. The medical technologies belonging to the cardiovascular, eHealth, gastrointestinal, neuromodulation, neurovascular, peripheral vascular, orthopedic, and other technology groups obtained positive status 1.

HTAs published by Spanish Health Institute Carlos III in July 2022

On July 20, 2022, Health Institute Carlos III released two HTA reports regarding endoanchoring systems in endovascular aortic aneurysm repair and transanal irrigation in bowel dysfunction.

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