Open transmyocardial laser revascularization may be considered medically necessary for individuals with NYHA class III or IV angina, who are not candidates for CABG surgery or PTCA surgery who meet ALL of the following criteria:
- Presence of NYHA class III or IV angina refractory to medical management; and
- Documentation of reversible ischemia; and
- Left ventricular ejection fraction greater than 30%; and
- No evidence of recent myocardial infarction or unstable angina within the last 21 days; and
- No severe comorbid illness such as chronic obstructive pulmonary disease (COPD).
Open transmyocardial laser revascularization may be considered medically necessary as an adjunct to CABG in those individuals with documented areas of ischemic myocardium that are not amenable to surgical revascularization.
Open transmyocardial laser revascularization is considered not medically necessary when performed for other conditions.