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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-33000-19

Original Effective Date: 06/15/00

Reviewed: 04/27/17

Revised: 05/15/17

Subject: Transmyocardial Revascularization (TMR)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Transmyocardial revascularization (TMR) is performed via a thoracotomy, with the patient under general anesthesia. Cardiopulmonary bypass is not required. A laser probe is placed on the surface of the myocardium, and while the heart is in diastole, the laser is discharged to create a channel through the myocardium into the left ventricle. Less invasive approaches to TMR are also being studied, including port access procedures using novel robotic and thoracoscopic techniques.

TMR can also be performed by the percutaneous route (ie, percutaneous transmyocardial revascularization [PTMR]). PTMR (now being called percutaneous myocardial channeling) is a catheter-based system using holmium:YAG laser revascularization under fluoroscopic guidance. It is performed in Europe but is not currently approved by the U.S. Food and Drug Administration. PTMR is performed by interventional cardiologists who create myocardial channels with lasers positioned at the endocardial surface inside the left ventricle. Although less invasive than TMR, there are potential disadvantages to the PTMR approach. To minimize the risks of cardiac tamponade, a potentially fatal condition in which the pericardium fills with blood, the myocardial channels created by PTMR are not as deep as those made by TMR. Also, positioning the laser under fluoroscopic guidance is less precise than the direct visual control of TMR. Less invasive (eg, robotic) techniques for use of this procedure are also being studied.

POSITION STATEMENT:

Open transmyocardial laser revascularization meets the definition of medical necessity for members with class III or IV angina, who are not candidates for coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA) surgery who meet ALL of the following criteria:

Open transmyocardial laser revascularization meets the definition of medical necessity as an adjunct to coronary artery bypass grafting (CABG) in those members with documented areas of ischemic myocardium that are amenable to surgical revascularization.

Open transmyocardial laser revascularization is considered experimental or investigational for all other indications not meeting the above criteria. The evidence is insufficient to determine the effects of the technology on health outcomes.

Percutaneous transmyocardial laser revascularization is considered experimental or investigational for all indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding

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-10 Diagnoses Codes That Support Medical Necessity

I20.0 – I20.9

Angina pectoris

I25.110 – I25.119

Atherosclerotic heart disease of native coronary artery with angina pectoris

I25.701– I25.799

Atherosclerosis with angina pectoris

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Transmyocardial Revascularization (TMR) (20.6) located at cms.gov.

DEFINITIONS:

Angina pectoris (angina): pain radiating from the heart caused by decreased blood supply to the myocardium.

Atherosclerosis: accumulation of plaque containing cholesterol and lipid material, within the inner walls of arteries.

Class III angina: Canadian Cardiovascular Society (CCS) functional classification for angina: Marked limitation of ordinary activity. Angina when walking one or two blocks on the level, or when climbing one flight of stairs at a normal pace.

Class IV angina: Canadian Cardiovascular Society (CCS) functional classification for angina: Inability to carry on any physical activity without discomfort. Angina may be present at rest.

Coronary artery disease: atherosclerotic blockage of the arteries supplying blood to the myocardium.

Ejection fraction: a clinical cardiac measurement – end-systolic volume-end-systolic volume end diastolic volume = ejection fraction.

Myocardium: the heart muscle.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Allen KB, Dowling RD, Schuch DR, Pfeffer TA, Marra S, Lefrak EA, Fudge TL, Mostovych M, Szentpetery S, Saha SP, Murphy D, Dennis H. Adjunctive transmyocardial revascularization: five-year follow-up of a prospective randomized trial. Ann Thorac Surg. 2004 Aug; 78(2): 458-65; discussion 458-65.
  2. Blue Cross Blue Shield Association TEC Assessment, TMR as an Adjunct to CABG Surgery for the Treatment of Coronary Artery Disease, 05/01.
  3. Blue Cross Blue Shield Association Medical Reference Policy Manual 7.01.54 Transmyocardial Revascularization, 02/17.
  4. Bridges CR, Horvath KA, Nugent WC, Shahian DM, Haan CK, Shemin RJ, Allen KB, Edwards FH. The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization. Ann Thorac Surg. 2004. Apr; 77:1494-1502.
  5. Briones E, Lacalle JR, Marin I. Transmyocardial laser revascularization versus medical therapy for refractory angina. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD003712.
  6. Centers for Medicare & Medicaid Services (CMS), NCD for Transmyocardial Revascularization (TMR), (20.6), located at cms.gov.
  7. Dallan LA, Gowdak LH, Lisboa LA, Schettert I, Krieger JE, Cesar LA, Oliveira SA, Stolf NA. Cell therapy plus transmyocardial laser revascularization: a proposed alternative procedure for refractory angina] Rev Bras Cir Cardiovasc. 2008 Mar;23(1):46-52. Portuguese.
  8. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM Jr, Lytle BW, Marlow RA, Nugent WC, Orszulak TA. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology Web Site. Accessed at: acc.org 04/09/11.
  9. Fihn SD, Gardin JM, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. Dec 18 2012;60(24):e44-e164.
  10. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, O’Rourke RA, Pasternak RC, Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. Accessed at: acc.org 04/09/11.
  11. Liao L, Sarria-Santamera A, Matchar DB, Huntington A, Lin S, Whellan DJ, Kong DF. Meta-analysis of survival and relief of angina pectoris after transmyocardial revascularization Am J Cardiol. 2005 May 15; 95(10): 1243-5.
  12. National Institute for Health and Clinical Excellence (NICE), Transmyocardial Laser Revascularisation for Refractory Angina Pectoris, Interventional Procedure Guidance 301, 05/09.
  13. Sarria-Santamera A,Liao L, Huntington A, Matchar D B. Percutaneous myocardial laser revascularization and transmyocardial laser revascularization. Rockville: Agency for Healthcare Research and Quality (AHRQ). 2004:131. Agency for Healthcare Research and Quality (AHRQ).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/27/17.

GUIDELINE UPDATE INFORMATION:

06/15/00

Medical Coverage Guideline developed.

09/15/01

Changes to "Covered Services" section.

10/15/03

Review and revision of guideline; consisting of updated references and addition of investigational statement for percutaneous myocardial revascularization.

10/15/05

Review and revision of guideline; consisting of updated references.

10/15/06

Review and revision of guideline consisting of updated references.

07/15/07

Annual review, coverage statement maintained, guideline reformatted, references updated.

10/15/08

Review and revision of guideline consisting of updated references.

07/15/09

Annual review: position statements maintained and references updated.

10/15/10

Revision; related ICD-10 codes added.

06/15/11

Scheduled review; position statements maintained, coding section and references updated.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; ICD9 & ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

05/15/17

Revision; Investigational position statement added; description, program exception and references updated.

Date Printed: October 21, 2017: 11:31 AM