HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-181-016
Topic:
Coronary Revascularization
Section:
Surgery
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
May 2022
 
 

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.

Policy Position

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;

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 an abnormal coronary flow 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 as indicated 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.

33210

33211

93024

93451

93452

93453

93456

93457

93458

93459

93460

93461

93462

93593

93594

93595

93596

93597

 

   



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.

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.

33140

33141

 

 

 

 

 




Payment can be made at 50% for the insertion of a temporary pacemaker when performed in conjunction with PCI.

Ergonovine testing is reported in conjunction with a cardiac catheterization only the cardiac catheterization may be considered medically necessary. Ergonovine testing is considered an integral part of the cardiac catheterization. It is not eligible as a distinct and separate service.

If ergonovine testing is reported on the same day as cardiac catheterization, and the charges are itemized, combine the charges and pay only the cardiac catheterization. Payment for the cardiac catheterization performed on the same date of service includes the allowance for the ergonovine testing.

33210

33211

93024

93451

93452

93453

93456

93457

93458

93459

93460

93461

93462

 




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.

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.

C7552

C7553

 

 

 

 

 




Related Policies

Refer to Medical Policy S-16, Assistant Surgery Eligibility Criteria, for additional information

Refer to Medical Policy S-60, Artificial Hearts and Ventricular Assist Devices, for additional information

Refer to Medical Policy S-100, Multiple Surgical Procedures, for additional information.


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, 33141

I20.1

I20.9

I25.9

 

 

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The cardiac procedures outlined in the above policy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.