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February 11, 2015

Percutaneous Transcatheter Septal Reduction Therapy: Coverage Guidelines

CGS considers percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion medically necessary for hypertrophic obstructive cardiomyopathy (HOCM) in adults when ALL of the following criteria are met:

  • Beneficiary has severe symptoms (e.g., dyspnea, angina pectoris, [pre]syncope, palpitations or heart failure) for at least 6 months despite optimal drug therapy (e.g., beta-blockers, calcium-antagonists), dual chamber pacing therapy and/or ineffective previous surgical myotomy/myectomy; and 
  • Beneficiary is classified as New York Heart Association class III or IV (see below); and
    • Class III Less than ordinary activity causes fatigue, palpitation, dyspnea or pain
    • Class IV Inability to carry out any physical activity. Symptoms of heart failure may be present at rest.
  • Beneficiary has classical, asymmetric subaortic HOCM identified by echocardiography, and not a mid-ventricular, a concealed membranous subaortic stenosis, nor supravalvular form; and 
  • Echocardiography shows left ventricular wall thickness of greater than 13 mm in adults in the absence of another cause for left ventricular hypertrophy; 15 mm in an athlete; and 
  • Beneficiary has systolic anterior motion of the mitral valve on echocardiography; and 
  • Beneficiary has a resting left ventricular outflow tract (LVOT) gradient of greater than 30 mm Hg or a stressed gradient of greater than 60 mm Hg, or member has less severe symptoms and LVOT of greater than 50 mm Hg at rest or greater than 100 mm Hg under stress; and 
  • Beneficiary does not have coronary artery disease that would preclude performance of the procedure.

Effective for dates of service on or after April 1, 2015, CGS will be implementing an edit to review for the above by criteria for the following ICD-9 codes listed below:

  • 413.0-413.9
  • 414.00-414.07
  • 425.11-425.18
  • 428.0-428.9
  • 780.2
  • 785.1
  • 786.09
  • V45.01

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