Medical Policy

Effective Date:07/01/2007 Title:Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)
Revision Date:10/01/2015 Document:BI201:00
CPT Code(s):C1886
Public Statement

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.

Medical Statement

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)

Limits

Percutaneous transluminal septal myocardial ablation is considered experimental and investigational for all other indications.

Reference
  1. Hayes Inc., Medical Technology Directory; Alcohol ablation for obstructive cardiomyopathy, Jan 2001.
  2. Spirito P. Alcohol septal ablation in the management of obstructive hypertrophic cardiomyopathy. Ital Heart J. 2000; 1(11):721-725. 
  3. Maron BJ. Role of alcohol septal ablation in treatment of obstructive hypertrophic cardiomyopathy. Lancet. 2000; 355(9202):425-426. 
  4. Seggewiss H. Current status of alcohol septal ablation for patients with hypertrophic cardiomyopathy. Curr Cardiol Rep. 2001; 3(2):160-166. 
  5. Kim JJ. Improvement in exercise capacity and exercise blood pressure response after transcoronary alcohol ablation therapy of septal hypertrophy in hypertrophic cardiomyopathy. Am J Cardiol. 1999; 83(8):1220-1223. 
  6. Kuhn H. Transcoronary ablation of septal hypertrophy (TASH): A new treatment option for hypertrophic obstructive cardiomyopathy. Z Kardiol. 2000; 89(Suppl 4):IV41-IV54. 
  7. Faber L. Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy: Long term follow up of the first series of 25 patients. Heart. 2000; 83(3):326-331. 
  8. Seggewiss H. Current status of alcohol septal ablation for patients with hypertrophic cardiomyopathy. Curr Cardiol Rep. 2001; 3(2):160-166.
  9. Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery. J Am Coll Cardiol.  2001; 38(7):1994-2000.
  10. Mutlak D, Gruberg L, Reisner S, et al. Non-surgical myocardial reduction in hypertrophic obstructive cardiomyopathy. Isr Med Assoc J. 2002; 4(2):86-90.
  11. Jiang T, Wu X, Jia C, et al. Percutaneous transluminal septal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy. Chin Med J (Engl). 2002; 115(1):26-30.
  12. Kovacic JC, Muller D. Hypertrophic cardiomyopathy: State-of-the-art review, with focus on the management of outflow obstruction. Intern Med J. 2003; 33(11):521-529.
  13. National Institute for Clinical Excellence (NICE). Interventional procedure overview of non-surgical reduction of myocardial septum. London, UK: NICE; November 2003. Available at: http://www.nice.org.uk/page.aspx?o=90963 .  Accessed September 13, 2005.
  14. Li ZQ, Cheng TO, Zhang WW, et al. Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy: The Chinese experience in 119 patients from a single center. Int J Cardiol. 2004;93(2-3):197-202.
  15. Veselka J, Prochazkova S, Duchonova R, et al. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Lower alcohol dose reduces size of infarction and has comparable hemodynamic and clinical outcome. Catheter Cardiovasc Interv. 2004;63(2):231-235.
  16. National Institute for Clinical Excellence (NICE).  Non-surgical reduction of myocardial septum.  Interventional Procedure Guidance 40.  London, UK: NICE; February 2004.  Available at: http://www.nice.org.uk/page.aspx?o=104270.  Accessed September 13, 2005. 
  17. van der Lee C, ten Cate FJ, Geleijnse ML, et al. Percutaneous versus surgical treatment for patients with hypertrophic obstructive cardiomyopathy and enlarged anterior mitral valve leaflets. Circulation. 2005;112(4):482-488.
  18. Alam M, Dokainish H, Lakkis N. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a systematic review of published studies. J Inter Cardiol. 2006 Aug.; 19(4); 319-327.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.