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.
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:
PCTA for any other indication is considered not medically necessary.
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.
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:
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.
Ergonovine testing is reported in conjunction with a cardiac catheterization only the cardiac catheterization may be considered medically necessary.
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.
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.|
Covered Diagnosis Codes for Procedure Codes S2205, S2206, S2207, S2208 and S2209
Covered Diagnosis Codes for Procedure Codes 33140 and 33141
Professional Statements and Societal Positions Guidelines