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CurrentAetnaPolicy 0558

Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)

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This policy governs the medical necessity and coverage criteria for alcohol-induced percutaneous transluminal septal myocardial ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM) in adults, and identifies indications considered experimental/investigational.

Policy Summary

PayerAetna

PolicyPercutaneous Transluminal Septal Myocardial Ablation (PTSMA)

Policy CodePolicy 0558

Change TypeNo material changes

Effective DateAug 14, 2001

Last ReviewJul 27, 2023

Next Review DateJun 13, 2024

Key ActionObtain prior authorization confirming that all medical necessity criteria are met before performing PTSMA (CPT 93583).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

93583CPT cited

>=13 mmLV wall thickness

30 mm HgResting LVOT threshold

1.8%In-hospital mortality

07/27/2023Last review

Coverage and Medical Necessity Criteria

Medical Necessity — Covered when ALL of the following are met

Covered when ALL of the following are met

PTSMA medical necessity: Member has severe symptoms (e.g., dyspnea, angina pectoris, [pre]syncope, palpitations or heart failure) for at least 6 months despite optimal drug therapy (e.g., beta-blockers, calcium-antagonists), dual chamber pacing therapy and/or ineffective previous surgical myotomy/myectomy.

NYHA class: Member is classified as New York Heart Association (NYHA) class III or IV.

Anatomic form of HOCM: Member has a classical, asymmetric subaortic HOCM identified by echocardiography (not mid-ventricular, concealed membranous subaortic stenosis, nor supravalvular form).

LV wall thickness: Echocardiography shows left ventricular wall thickness greater than 13 mm in adults in the absence of another cause for LV hypertrophy (15 mm in an athlete).> 13 mm (15 mm in athlete)

Systolic anterior motion: Member has systolic anterior motion of the mitral valve on echocardiography.

LVOT gradient: Member has a resting LVOT gradient > 30 mm Hg or a stressed LVOT gradient > 60 mm Hg; alternatively, for less severe symptoms, resting > 50 mm Hg or stressed > 100 mm Hg.resting >30 mm Hg OR stressed >60 mm Hg (alternatives: resting >50 mm Hg or stressed >100 mm Hg)

Coronary artery disease exclusion: Member does not have coronary artery disease that would preclude performance of the procedure.

Aetna considers percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion medically necessary only for adult patients with hypertrophic obstructive cardiomyopathy (HOCM) who meet all of the specified medical necessity criteria. These criteria require: severe symptoms for at least 6 months despite optimal drug therapy, dual-chamber pacing and/or prior ineffective myotomy/myectomy; NYHA class III or IV; classical asymmetric subaortic HOCM on echocardiography (excluding mid-ventricular, concealed membranous subaortic stenosis, and supravalvular forms); echocardiographic left ventricular wall thickness > 13 mm in adults (or > 15 mm in an athlete); systolic anterior motion of the mitral valve; and a left ventricular outflow tract (LVOT) gradient of > 30 mm Hg resting or > 60 mm Hg stressed (alternative thresholds for less severe symptoms: > 50 mm Hg resting or > 100 mm Hg stressed), with no coronary artery disease that would preclude the procedure.

Any use of PTSMA for indications other than the adult HOCM presentation that meets the policy’s listed criteria is considered experimental and investigational because of insufficient evidence of safety and effectiveness, and therefore is not covered.

Codes and Clinical Thresholds

Covered CPT Codes (if selection criteria met)CPTCovered

93583

Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including temporary pacemaker insertion when performed.

Related HCPCS CodesHCPCS

C1886

Catheter, extravascular tissue ablation, any modality (insertable).

ICD-10 Diagnosis Codes (covered if selection criteria met)ICD-10Covered

I42.1

Obstructive hypertrophic cardiomyopathy

Left ventricular wall thickness — criterion values

Adult LV wall thicknessGreater than 13 mm in adults (in the absence of another cause for LV hypertrophy)

Athlete threshold15 mm in an athlete

Measurement modalityDetermined by echocardiography as specified in policy criteria

LVOT gradient thresholds

Primary resting thresholdResting LVOT gradient > 30 mm Hg

Primary stressed thresholdStressed LVOT gradient > 60 mm Hg

Alternative thresholds for less severe symptomsResting > 50 mm Hg or stressed > 100 mm Hg

Provider Requirements and Authorization

Prior Authorization

Prior authorization not specified in the provided excerpt. The policy text does not state any operational prior authorization procedures or explicit authorization/denial triggers for CPT 93583 or related codes.

No prior authorization procedure described in excerpt
No operational authorization/denial triggers present

Documentation Required

Documentation Requirements

Documentation must demonstrate that all medical necessity criteria are met. Records should support symptom duration, NYHA class, echocardiographic findings (including LV wall thickness, systolic anterior motion, LVOT gradients), prior optimal medical therapy, and absence of coronary disease that would preclude the procedure.

Symptom duration ≥ 6 months despite optimal drug therapy and other measures
NYHA class III or IV documented
Echocardiography: asymmetric subaortic HOCM, LV wall thickness (>13 mm adults; 15 mm for athletes), systolic anterior motion, LVOT gradient values
Documentation of prior therapies/trials (beta-blockers, calcium-antagonists, DDD pacing, prior myotomy/myectomy) and their outcomes
Absence of coronary artery disease that would preclude procedure

Note

Prior Therapies Required

Patients should have had optimal medical therapy and consideration/trial of device therapy where applicable prior to PTSMA. The excerpt specifies at least 6 months of severe symptoms despite optimal drug therapy (e.g., beta-blockers, calcium-antagonists), dual-chamber pacing therapy and/or ineffective previous surgical myotomy/myectomy. Allow sufficient time to assess effects of chronic DDD pacing when used.

Optimal drug therapy: beta-blockers, calcium-antagonists
Consideration/trial of DDD (dual‑chamber) pacing where applicable
Previous surgical myotomy/myectomy documented as ineffective when applicable
Allow adequate follow-up time to assess DDD pacing benefits

Step Therapy

No step therapy requirements are described in the provided portion of the document.

Excerpt contains no step therapy or quantity-limit constraints

Note

Policy History / Disclaimer

The document portion includes policy history and a disclaimer. The policy history shows last review dates and effective/next review dates; the bulletin includes the standard Aetna disclaimer about the policy being informational and subject to change.

Effective date: 08/14/2001
Last review: 07/27/2023
Next review: 06/13/2024
Policy disclaimer: bulletin not a contract; subject to change

Denial Risk

Coverage Limitations

Procedures for indications other than adult hypertrophic obstructive cardiomyopathy (HOCM) meeting the stated criteria are considered experimental/investigational and are not eligible for coverage per the excerpt.

PTSMA considered experimental/investigational for all other indications

Clinical Background

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by asymmetric interventricular septal hypertrophy that can produce a dynamic left ventricular outflow tract (LVOT) gradient. Systolic anterior motion (SAM) of the mitral valve frequently contributes to obstruction and symptoms such as dyspnea, angina, presyncope or syncope. Echocardiography is the primary diagnostic modality used to document asymmetric septal thickening, SAM, and to quantify the resting and provoked LVOT gradients that guide therapy.

Definitions and Classifications

NYHA Classification — functional classes I–IV

Class INo limitation of physical activity; ordinary activity does not cause symptoms (e.g., dyspnea, angina).

Class IISlight limitation of physical activity; comfortable at rest but ordinary activity results in symptoms.

Class IIIMarked limitation of physical activity; comfortable at rest but less than ordinary activity causes symptoms.

Class IVUnable to carry on any physical activity without discomfort; symptoms may be present at rest.

PTSMA definition — percutaneous alcohol septal ablation

Definition summaryA percutaneous procedure in which alcohol is instilled into selected septal branches to induce a localized myocardial infarction and reduce interventricular septal thickness and LVOT gradient.

Indication in policyConsidered medically necessary for adult HOCM when all listed criteria (including symptomatic status, echocardiographic findings, and LVOT gradients) are met.

Alternative to surgeryDescribed as an alternative to surgical myectomy in selected patients as part of background context.

Policy History and References

2001-08-14policy_effective

Policy became effective.

2023-07-27last_reviewLatest

Policy was last reviewed.

2024-06-13next_review

Next scheduled policy review date.

Policy Summary

PayerAetna

PolicyPercutaneous Transluminal Septal Myocardial Ablation (PTSMA)

Policy CodePolicy 0558

Change TypeNo material changes

Effective DateAug 14, 2001

Last ReviewJul 27, 2023

Next Review DateJun 13, 2024

Key ActionObtain prior authorization confirming that all medical necessity criteria are met before performing PTSMA (CPT 93583).

SourceLink

On This Page

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Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)

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Sign up for Aetna Policy 0558 alerts

Get alerted when Policy 0558 changes without checking for updates manually.

We'll notify you when Aetna policy 0558 is updated.

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Coverage and Medical Necessity Criteria

Medical Necessity — Covered when ALL of the following are met

Covered when ALL of the following are met

NYHA class: Member is classified as New York Heart Association (NYHA) class III or IV.

Anatomic form of HOCM: Member has a classical, asymmetric subaortic HOCM identified by echocardiography (not mid-ventricular, concealed membranous subaortic stenosis, nor supravalvular form).

Systolic anterior motion: Member has systolic anterior motion of the mitral valve on echocardiography.

Coronary artery disease exclusion: Member does not have coronary artery disease that would preclude performance of the procedure.

Codes and Clinical Thresholds

Covered CPT Codes (if selection criteria met)CPTCovered

93583

Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including temporary pacemaker insertion when performed.

Related HCPCS CodesHCPCS

C1886

Catheter, extravascular tissue ablation, any modality (insertable).

ICD-10 Diagnosis Codes (covered if selection criteria met)ICD-10Covered

I42.1

Obstructive hypertrophic cardiomyopathy

Left ventricular wall thickness — criterion values

Adult LV wall thicknessGreater than 13 mm in adults (in the absence of another cause for LV hypertrophy)

Athlete threshold15 mm in an athlete

Measurement modalityDetermined by echocardiography as specified in policy criteria

LVOT gradient thresholds

Primary resting thresholdResting LVOT gradient > 30 mm Hg

Primary stressed thresholdStressed LVOT gradient > 60 mm Hg

Alternative thresholds for less severe symptomsResting > 50 mm Hg or stressed > 100 mm Hg

Provider Requirements and Authorization

Prior Authorization

No prior authorization procedure described in excerpt
No operational authorization/denial triggers present

Documentation Required

Documentation Requirements

Symptom duration ≥ 6 months despite optimal drug therapy and other measures
NYHA class III or IV documented
Echocardiography: asymmetric subaortic HOCM, LV wall thickness (>13 mm adults; 15 mm for athletes), systolic anterior motion, LVOT gradient values
Documentation of prior therapies/trials (beta-blockers, calcium-antagonists, DDD pacing, prior myotomy/myectomy) and their outcomes
Absence of coronary artery disease that would preclude procedure

Note

Prior Therapies Required

Optimal drug therapy: beta-blockers, calcium-antagonists
Consideration/trial of DDD (dual‑chamber) pacing where applicable
Previous surgical myotomy/myectomy documented as ineffective when applicable
Allow adequate follow-up time to assess DDD pacing benefits

Step Therapy

No step therapy requirements are described in the provided portion of the document.

Excerpt contains no step therapy or quantity-limit constraints

Note

Policy History / Disclaimer

Effective date: 08/14/2001
Last review: 07/27/2023
Next review: 06/13/2024
Policy disclaimer: bulletin not a contract; subject to change

Denial Risk

Coverage Limitations

PTSMA considered experimental/investigational for all other indications

Clinical Background

Definitions and Classifications

NYHA Classification — functional classes I–IV

Class INo limitation of physical activity; ordinary activity does not cause symptoms (e.g., dyspnea, angina).

Class IISlight limitation of physical activity; comfortable at rest but ordinary activity results in symptoms.

Class IIIMarked limitation of physical activity; comfortable at rest but less than ordinary activity causes symptoms.

Class IVUnable to carry on any physical activity without discomfort; symptoms may be present at rest.

PTSMA definition — percutaneous alcohol septal ablation

Indication in policyConsidered medically necessary for adult HOCM when all listed criteria (including symptomatic status, echocardiographic findings, and LVOT gradients) are met.

Alternative to surgeryDescribed as an alternative to surgical myectomy in selected patients as part of background context.

OpenPayer

Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)

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Coverage and Medical Necessity Criteria

Codes and Clinical Thresholds

Provider Requirements and Authorization

Clinical Background

Definitions and Classifications

Policy History and References

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OpenPayer

Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)

Sign up for Aetna Policy 0558 alerts

Coverage and Medical Necessity Criteria

Codes and Clinical Thresholds

Provider Requirements and Authorization

Clinical Background

Definitions and Classifications

Policy History and References