Effective Date:
a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.
b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.
1) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) is a minimally invasive treatment of an unusual form of cardiomyopathy.
2) PTSMA is done to improve the heart`s ability to pump blood when the septum has become enlarged and thickened from Hypertrophic Obstructive Cardiomyopathy (HOCM). The septum is the heart muscle that separates the right and left ventricles of the heart. The septal enlargement and thickening blocks the heart from being able to pump blood out efficiently. HOCM may cause symptoms such as chest pain, shortness of breath, and dizziness, especially with exertion. HOCM may even cause sudden death.
3) PTSMA requires pre-authorization.
1) Percutaneous Transluminal Septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion is considered medically necessary for hypertrophic obstructive cardiomyopathy (HOCM) (I42.1) in adults when all of the following criteria are met:
a) Member has severe symptoms (e.g., dyspnea (R06.00 – R06.09), angina pectoris (I20.0 – I20.9), [pre]syncope (R55), palpitations (R00.2) or heart failure (I50.1 – I50.9)) despite optimal drug therapy (e.g., beta-blockers, calcium-antagonists), dual chamber pacing (DDD) therapy and/or ineffective previous surgical myotomy/myectomy; and
b) Member is classified as New York Heart Association class III or IV ; and
c) Member has a classical, asymmetric subaortic HOCM identified by echocardiography (ECHO), and no other forms of cardiomyopathy; and
d) ECHO shows left ventricular wall thickness of greater than 13 mm in adults in the absence of another cause for left ventricular hypertrophy (LVH); and
e) Member has systolic anterior motion of the mitral valve on ECHO; and
f) Member 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
g) Member does not have coronary artery disease (CAD) that would preclude performance of the procedure. HAYES B
The Stages of Heart Failure – NYHA Classification
In order to determine the best course of therapy, physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient`s quality of life.
Class Patient Symptoms Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Codes Used In This BI:
C1886 Catheter, extravascular tissue ablation, any modality (insertable)
Percutaneous transluminal septal myocardial ablation is considered experimental and investigational for all other indications.