Coronary Revascularization

Policy ID: S-181-015

Section: Surgery

Effective Date: July 01, 2018

Revised Date: February 10, 2023

Revision Effective Date: January 01, 2023

Last Reviewed: March 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Coronary revascularization is the process of restoring the flow of blood to the heart. This is done by removing or bypassing (going around) blockages in coronary arteries caused by atherosclerosis.

Criteria

Percutaneous coronary intervention (PCI), may be considered medically necessary for the treatment of obstructions in the coronary arteries, when ANY of the following criteria are met:

As an alternative to coronary artery bypass grafting (CABG), in stable individuals with significant (greater than or equal to 50% diameter) coronary artery stenoses in unprotected left main coronary artery disease (CAD) with BOTH of the following:
- Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes from CABG; and
- Anatomic conditions associated with a low risk of procedural complications and a high likelihood of good long-term outcome;

Symptomatic individuals with one (1) or more significant (greater than or equal to 70% diameter) coronary artery stenoses when amenable to revascularization and with NYHA class II, III or IV angina refractory to maximal medical therapy; or
Symptomatic individuals with one (1) or more significant (greater than or equal to 70% diameter) coronary artery stenoses (either a native coronary artery or bypassed graft vessel) * with history of previous CABG, and with NYHA class II, III or IV angina refractory to maximal medical therapy; or
Symptomatic individuals with one (1) or more intermediate (50% to 69% diameter) coronary artery stenoses with an abnormal coronary flow reserve assessment or appropriate imaging of less than or equal to 0.80, and with NYHA class II, III or IV angina refractory to maximal medical therapy.

PCI not meeting the criteria in this policy is considered not medically necessary.

Cardiac catheterization and pre/post-injections for angiographic studies are eligible for separate payment in accordance with multiple surgery guidelines.

Procedure Codes

92920

92921

92924

92925

92928

92929

92933

92934

92937

92938

92941

92943

92944

Minimally invasive direct coronary artery bypass (MIDCAB) may be considered medically necessary for the treatment of atherosclerosis.

MIDCAB procedures not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

S2205

S2206

S2207

S2208

S2209

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 PCI surgery who meet ALL of the following criteria:

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); and
Presence of NYHA class III or IV angina refractory to medical management.

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 procedures not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33140

33141

Ergonovine testing is reported in conjunction with a cardiac catheterization only the cardiac catheterization may be considered medically necessary.

Procedure Codes

33210

33211

93024

93451

93452

93456

93457

93458

93459

93460

93461

93462

93593

93594

93595

93596

93597

93598

The following procedures are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness cannot be determined by the available published peer-reviewed literature.

Percutaneous transmyocardial laser revascularization
MIDCAB surgery, that includes the use of robotics not performed under direct visualization.

Procedure Codes

33999

New York Heart Association (NYHA) Classification of Heart Failure

Class I

No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations.

Class II

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class III

Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class IV

Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased.

Outpatient HCPCS (C Codes)

C7552

C7553

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: S2205, S2206, S2207, S2208, and S2209

I25.10

I25.110

I25.111

I25.112

I25.118

I25.119

I25.700

I25.701

I25.702

I25.708

I25.709

I25.710

I25.711

I25.712

I25.718

I25.719

I25.720

I25.721

I25.722

I25.728

I25.729

I25.730

I25.731

I25.732

I25.738

I25.739

I25.750

I25.751

I25.752

I25.758

I25.759

I25.760

I25.761

I25.762

I25.768

I25.769

I25.790

I25.791

I25.792

I25.798

I25.799

I25.810

I25.811

I25.812

Covered Diagnosis Codes for Procedure Codes: 33140, and 33141

I20.1

I20.8

I20.9

I25.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 3-17-2021 Annual Review

Internal Medical Policy Committee 5-20-2021 Revision-updating criteria and language

Internal Medical Policy Committee 01-20-2022 Coding update-Effective January 01, 2022

Added procedure codes: 93593, 93594, 93595, 93596, 93597, and 93598
Removed procedure codes: 93530, 93531, 93532, and 9533.

Internal Medical Policy Committee 7-21-2022 Revision with coding updates

Internal Medical Policy Committee 9-28-2022 Coding update-Effective October 01, 2022

Added the following Diagnosis codes: I25.112; I25.702; I25.712; I25.722; I25.732; I25.752; I25.762; I25.792.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 01, 2023

Added C7552 and C7553

Internal Medical Policy Committee 3-23-2023 Coding update

Removed procedure code 93543

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-181-014

Section: Surgery

Effective Date: July 01, 2018

Revised Date: September 20, 2022

Revision Effective Date: October 01, 2022

Last Reviewed: September 28, 2022

Archived Date: December 31, 2022

Applies To: Commercial and Medicaid Expansion

Description

Coronary revascularization is the process of restoring the flow of blood to the heart. This is done by removing or bypassing (going around) blockages in coronary arteries caused by atherosclerosis.

Criteria

Percutaneous coronary intervention (PCI), may be considered medically necessary for the treatment of obstructions in the coronary arteries, when ANY of the following criteria are met:

As an alternative to coronary artery bypass grafting (CABG), in stable individuals with significant (greater than or equal to 50% diameter) coronary artery stenoses in unprotected left main coronary artery disease (CAD) with BOTH of the following:
- Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes from CABG; and
- Anatomic conditions associated with a low risk of procedural complications and a high likelihood of good long-term outcome;

Symptomatic individuals with one (1) or more significant (greater than or equal to 70% diameter) coronary artery stenoses when amenable to revascularization and with NYHA class II, III or IV angina refractory to maximal medical therapy; or
Symptomatic individuals with one (1) or more significant (greater than or equal to 70% diameter) coronary artery stenoses (either a native coronary artery or bypassed graft vessel) * with history of previous CABG, and with NYHA class II, III or IV angina refractory to maximal medical therapy; or
Symptomatic individuals with one (1) or more intermediate (50% to 69% diameter) coronary artery stenoses with an abnormal coronary flow reserve assessment or appropriate imaging of less than or equal to 0.80, and with NYHA class II, III or IV angina refractory to maximal medical therapy.

PCI not meeting the criteria in this policy is considered not medically necessary.

Cardiac catheterization and pre/post-injections for angiographic studies are eligible for separate payment in accordance with multiple surgery guidelines.

Procedure Codes

92920

92921

92924

92925

92928

92929

92933

92934

92937

92938

92941

92943

92944

Minimally invasive direct coronary artery bypass (MIDCAB) may be considered medically necessary for the treatment of atherosclerosis.

MIDCAB procedures not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

S2205

S2206

S2207

S2208

S2209

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); and
Presence of NYHA class III or IV angina refractory to medical management.

Open transmyocardial laser revascularization procedures not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33140

33141

Ergonovine testing is reported in conjunction with a cardiac catheterization only the cardiac catheterization may be considered medically necessary.

Procedure Codes

33210

33211

93024

93451

93452

93543

93456

93457

93458

93459

93460

93461

93462

93593

93594

93595

93596

93597

93598

Percutaneous transmyocardial laser revascularization
MIDCAB surgery, that includes the use of robotics not performed under direct visualization.

Procedure Codes

33999

New York Heart Association (NYHA) Classification of Heart Failure

Class I

No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations.

Class II

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class III

Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class IV

Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: S2205, S2206, S2207, S2208, and S2209

I25.10

I25.110

I25.111

I25.112

I25.118

I25.119

I25.700

I25.701

I25.702

I25.708

I25.709

I25.710

I25.711

I25.712

I25.718

I25.719

I25.720

I25.721

I25.722

I25.728

I25.729

I25.730

I25.731

I25.732

I25.738

I25.739

I25.750

I25.751

I25.752

I25.758

I25.759

I25.760

I25.761

I25.762

I25.768

I25.769

I25.790

I25.791

I25.792

I25.798

I25.799

I25.810

I25.811

I25.812

Covered Diagnosis Codes for Procedure Codes: 33140, and 33141

I20.1

I20.8

I20.9

I25.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 3-17-2021 Annual Review

Internal Medical Policy Committee 5-20-2021 Revision-updating criteria and language

Internal Medical Policy Committee 01-20-2022 Coding update-Effective January 01, 2022

Added procedure codes: 93593, 93594, 93595, 93596, 93597, and 93598
Removed procedure codes: 93530, 93531, 93532, and 9533.

Internal Medical Policy Committee 7-21-2022 Revision with coding updates

Internal Medical Policy Committee 9-28-2022 Coding update-Effective October 01, 2022

Added the following Diagnosis codes: I25.112; I25.702; I25.712; I25.722; I25.732; I25.752; I25.762; I25.792.

Links

References (PDF)

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search

Stay updated on HealthCare News