Coronary Revascularization

Section: Surgery
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

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 transluminal coronary angioplasty (PTCA), including laser and/or balloon techniques 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.

OR

  • 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 a Fractional Flow Reserve (FFR*) of less than or equal to 0.80, and with NYHA class II, III or IV angina refractory to maximal medical therapy.

PCTA for any other indication is considered not medically necessary.

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 is considered not medically necessary when performed for all other conditions.

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 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.

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 93548 93459 93460 93461 93462 93530
93531 93532 93533

The following procedures are considered experimental/investigational and, therefore, non-covered. Scientific evidence does not support the use of these procedures; there is insufficient evidence to conclude that these techniques provide comparable outcomes to conventional treatments.

  • 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 I25.118 I25.119 I25.700 I25.701
I25.708 I25.709 I25.710 I25.711 I25.718 I25.719 I25.720
I25.721 I25.728 I25.729 I25.730 I25.731 I25.738 I25.739
I25.750 I25.751 I25.758 I25.759 I25.760 I25.761 I25.768
I25.769 I25.790 I25.791 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

NA

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