LCD L34761: Percutaneous Coronary Interventions

Overview

Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty or simply angioplasty, is a non-surgical procedure used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease. These stenotic segments are due to the buildup of the cholesterol-laden plaques that form due to atherosclerosis. During PCI, a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. A stent is often placed at the site of blockage to permanently open the artery.

Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.

Indications:

Percutaneous coronary intervention (PCI) may be indicated in the management of patients with:

• acute coronary syndrome (e.g., acute myocardial infarction, unstable angina);

• a history of significant obstructive atherosclerotic disease;

• restenosis of a coronary artery previously treated with intracoronary stent or another revascularization procedure;

• chronic angina; or

• silent ischemia

Intracoronary ultrasound (IVUS) may be separately covered when needed to assess the extent of coronary stenosis if equivocal on angiography, or when needed to assess the patency and integrity of a coronary artery during percutaneous coronary intervention. Alternatively, intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement may be performed to assess the degree of stenosis within a vessel. Intracoronary ultrasound or fractional flow reserve measurement should be performed on an individual artery as clinically indicated. Both procedures are not considered medically necessary unless written documentation is submitted to support medical necessity. Intracoronary ultrasound and Doppler fractional flow reserve studies can be required in multivessel coronary artery disease (CAD).

A diagnostic cardiac catheterization to assess the nature of the lesion(s) prior to the intervention is a covered service. The diagnostic cardiac catheterization may be performed at any time prior to the PCI, including the same day as the PCI. Performance of a diagnostic cardiac catheterization and interventional procedure on the same day is increasingly the standard of practice. If the diagnostic catheterization is done within 30 days of the PCI, it is usually not necessary to repeat the catheterization unless there is a documented change in the patient’s condition. While there may be reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center, excessive dye load, further treatment planning or evaluation of angiography, etc.), it is recommended that both procedures be performed during the same encounter when medically appropriate, with detailed discussion of benefits and risks of PCI. Separation of these procedures for the purpose of circumventing the multiple surgery pricing, or for the convenience of physician or hospital scheduling, is considered an inappropriate practice and may subject the services to review and denial for medical necessity. The decision to stage these procedures is deferred to the judgment of the interventional cardiologist and individualized only to the clinical needs of the patient. (e.g., dye load already received; need to correlate findings with other test results, etc.). Reasons for delaying an indicated percutaneous coronary intervention should be documented in the medical record. Unless there is a new clinical event, a change in symptomatology, abnormal examination or other test results, a repeat diagnostic catheterization within 3 months of the last diagnostic catheterization and prior to the percutaneous coronary intervention is generally not reimbursable and is considered not reasonable and necessary.

Limitations:

Generally, PCI is not indicated for:

• Patients that can be managed medically.

• Right heart catheterization and insertion of a Swan - Ganz catheter are not generally medically necessary for a PCI and will be denied, unless medically necessary when performed incident to a diagnostic catheterization prior to the intervention.

• Standby services of a surgeon or anesthesiologist are not covered services.

• Patient with stable CAD.

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