LCD/NCD Portal

L29295

 

TRANSMYOCARDIAL REVASCULARIZATION

 

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

• Studies indicate that both reduction in pain and reduction in hospitalizations are significant for most patients treated.

• Consequently, CMS has concluded that, for patients with severe angina (Class III or IV, Canadian Cardiovascular Society, or similar classification system) for whom all other medical have been tried or evaluated and found insufficient, such therapy offers sufficient evidence of its medical effectiveness to treat the symptomatology.

• It is important to note that this technique does not provide for increased life expectancy, nor is it proven to affect the underlying cause of the angina.

• However, it appears effective in treating the symptoms of angina and reducing hospitalizations and allowing patients to resume some of their normal activities of daily living.

Medicare will cover TMR as medically reasonable and necessary when all of the following criteria are met:

• TMR is a late or last resort for patients with severe (Canadian Cardiovascular Society classification of class III or IV) angina (stable or unstable) which has been found refractory to standard medical therapy, including drug therapy at the maximum tolerated or maximum safe dosages.

• The angina symptoms must be caused by areas of the heart not amendable to surgical therapies such as percutaneous transluminal coronary angioplasty, stenting, coronary atherectomy or coronary bypass.

• Coverage is further limited to those uses of the laser used in performing the procedure which have been approved by the Food and Drug Administration for the purpose for which they are being used

• Patients must also meet all of the following selection guidelines

o Have and ejection fraction of 25 % or greater

o Have areas of viable ischemic myocardium (as demonstrated by diagnostic study) which are not capable of being revascularized by direct coronary intervention

o Have been stabilized, or have had maximal efforts to stabilize acute conditions such as severe ventricular arrhythmias, decompensated congestive heart failure or acute myocardial infarction.

• The following coverage requirements must also be met:

o Physicians must be properly trained in the procedure.

o Providers of this service must also document that all the ancillary personnel, including physicians, nurses, operating room personnel and technicians, are properly trained in the procedure and the proper use of the equipment involved.

o Providers must have dedicated cardiac care units, including the diagnostic and support services necessary for care of patients undergoing this therapy.

o Providers must conform to the standards for laser safety set by the American National Standards Institute, ANSIZ1363.

 

 

CPT/HCPCS Codes

 

33140 TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; (SEPARATE PROCEDURE)

33141 TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; PERFORMED AT THE TIME OF OTHER OPEN CARDIAC PROCEDURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

 

 

ICD-9 Codes that Support Medical Necessity

 

411.1 INTERMEDIATE CORONARY SYNDROME

413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS

 

 

Documentation Requirements

• The medical record documentation must support that the patient meets all of the criteria contained in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

o In addition, the documentation must support that the service was performed.

o This information is usually found in the history and physical, progress note, operative note, diagnostic test results, and/or discharge summary.

• Documentation verifying the laser’s FDA approval, appropriate training of the physician and all ancillary personnel, facility requirements, and that the laser safety standards are being followed must be available at the facility.

Treatment Logic

• Transmyocardial Revascularization (TMR) is a surgical technique that uses a laser to bore holes through the myocardium of the heart in an attempt to restore perfusion to areas of the heart not being reached by diseased or clogged arteries.

• This technique is used as a late or last resort for relief of symptoms of severe angina in patients with ischemic heart disease not amendable to direct coronary revascularization interventions, such as angioplasty, stenting or open coronary bypass.

• The precise workings of this technique are not certain.

• The original theory, upon which the technique was based, that the open channels would result in increased perfusion of the myocardium, does not appear to be the major or only action at work.

• Several theories have been proposed, including partial denervation of the myocardium or the triggering of the cascade of biological reactions, which encourage increased development of blood vessels.

• However, research at several facilities indicates that, despite this uncertainty, the technique does offer relief of angina symptoms for a period of time in patients for whom no other medical treatment offering relief is available.

• Studies indicate that both reduction in pain and reduction in hospitalizations are significant for most patients treated.

 

 

Sources of Information and Basis for Decision

 

Bhimji, S. (2005). Transmyocardial Laser Revascularization. Retrieved from http://www.emedicine.com/med/topic3575.htm on 6/9/2005.

 

Bridges, C; Horvath, K; et al (2003). The Society of Thoracic Surgeons Practice Guideline Series- Transmyocardial Laser Revascularization. Retrieved from http://www.sts.org/doc/8228 on June 9, 2005.

 

Cleveland Clinic Heart Center. TMR (Transmyocardial Laser Revascularization) A new surgical procedure for inoperable coronary artery disease patients with angina (chest pain). Retrieved from http://www.clevelandclinic.org/heartcenter/pub/guide/diasease/cad/TMR.htm on June 9, 2005.

 

Hayden, A. Transmyocardial Revascularization. RN Web [Online]. Available: http://www.rnweb.com/ce/transmyoc.html.

 

Sanni, A., and Dunning, J (2004). Is transmyocardial revascularization of benefit to people with ‘no option’ angina? Interactive Cardiovascular and Thoracic Surgery 3: 586-592.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD TRANSMYOCARDIAL REVASCULARIZATION