CurrentBlue Cross Blue Shield - MassachusettsPolicy 116

Cardiac Catheterization and Angiography Policy

Defines medical necessity indications, coding, and prior authorization requirements for right heart catheterization, left heart catheterization (including transseptal), cardiac angiography (coronary and intracardiac), pulmonary angiography, intracoronary ultrasound/FFR, physiologic exercise hemodynamics, extra-cardiac angiography performed with cardiac catheterization, and related procedures for commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCardiac Catheterization and Angiography Policy

Policy CodePolicy 116

Change TypeClarified / Added / Revised

Effective DateOct 14, 2024

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if the procedure is performed inpatient; ensure medical necessity criteria are met and documented for listed CPT codes.

SourceLink

POLICY UPDATE CHANGES

Intracoronary ultrasound section clarified and referral to MP 117 for Doppler/FFR statements.

Updated link to Billing and Coding article A52850.

New medical policy added describing medically necessary and not medically necessary indications (effective 2024-10-14).

10+Major distinct procedure categories covered

30+CPT codes listed

2Prior auth settings (inpatient required; outpatient not required for many commercial products)

1Related policy (PCI #117)

Coverage Summary

Overview: This policy (Policy Number 116) addresses coverage criteria for cardiac catheterization and angiography, defining medical necessity indications, coding, and prior authorization requirements for right and left heart catheterization (including transseptal approaches), coronary and extra‑cardiac angiography, intracoronary imaging and physiologic testing, exercise hemodynamics, and endomyocardial biopsy. Effective date: 2024-10-14; Last review: 2024-11-01. Coverage stance: covered_with_criteria — procedures are covered when the policy’s medical necessity criteria and documentation requirements are met.

Policy metadata

policy_number116

effective_date2024-10-14

last_review2024-11-01

next_review

coverage_stancecovered_with_criteria

scope_summaryDefines medical necessity indications, coding, and prior authorization requirements for right and left heart catheterization (including transseptal), cardiac and pulmonary angiography, intracoronary ultrasound/FFR, physiologic exercise hemodynamics, extra-cardiac angiography performed with cardiac catheterization, endomyocardial biopsy, and related procedures for commercial members.

Medical-Necessity Criteria

Right Heart Catheterization - Medically Necessary

Right heart catheterization is MEDICALLY NECESSARY to evaluate:

ALL of the following

Valvular heart disease.
Congestive heart failure.
Cor pulmonale.
Congenital heart disease.
Pulmonary hypertension.

Coding

Covered CPTCPTCovered

93451	Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed.
93453	Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.
93456	Catheter placement in coronary artery(s) for coronary angiography; with right heart catheterization.
93457	Catheter placement in coronary artery(s) for coronary angiography; with catheter placement(s) in bypass graft(s) including bypass graft angiography and right heart catheterization.
93460	Catheter placement in coronary artery(s) for coronary angiography; with right and left heart catheterization including left ventriculography, when performed.
93461	Catheter placement in coronary artery(s) for coronary angiography; with right and left heart catheterization and bypass graft angiography.
93458	Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization including left ventriculography, when performed.
93459	Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization and bypass graft angiography.
93454	Catheter placement in coronary artery(s) for coronary angiography, imaging supervision and interpretation.
93455	Catheter placement in coronary artery(s) for coronary angiography; with catheter placement(s) in bypass graft(s) including bypass graft angiography.

1–10 of 22

1/3

Covered ICD-10 Diagnosis (examples listed)ICD-10Covered

I22.9	Subsequent ST elevation (STEMI) myocardial infarction of unspecified site.
I40.9	Acute myocarditis, unspecified.

Extra-Cardiac Angiography Pairing Rules (CPT)mixedCovered

75625	When billed with Column 2 CPT 36140 and Column 3 CPT 93451 (example pairing).
75630	When billed with Column 2 CPT 36200 and Column 3 CPT 93453 (example pairing).
75705	When billed with Column 2 CPT 36215 and Column 3 CPT 93456 (example pairing).
75710	When billed with Column 2 CPT 36216 and Column 3 CPT 93457 (example pairing).
75716	When billed with Column 2 CPT 36217 and Column 3 CPT 93460 (example pairing).

Provider Actions

Prior Authorization

Precertification/Preauthorization required for inpatient procedures

Precertification/preauthorization is required if the procedure is performed inpatient for all products.

Prior Authorization

Outpatient prior authorization not required for certain products

For outpatient procedures, prior authorization is not required for Commercial Managed Care (HMO and POS), PPO, and Indemnity products.

Background and Definitions

Background and scope: The policy defines the procedures included under cardiac catheterization — right heart catheterization (introduction of catheters into the right atrium, right ventricle and pulmonary artery with hemodynamic measurements), left heart catheterization (retrograde, transseptal, or transapical access to the left ventricle, with associated measurements and sampling), transseptal puncture technique, coronary and intracardiac angiography, pulmonary and extra‑cardiac angiography, intracoronary ultrasound/FFR studies, physiologic exercise hemodynamics, and endomyocardial biopsy.

Differentiation from Swan‑Ganz/monitoring catheters: Right heart catheterization in this policy is described as a formal diagnostic procedure performed in a catheterization or procedure suite with a formal report, and is distinguished from Swan‑Ganz catheterization, which is generally used for ongoing bedside monitoring and whose results may be recorded in progress notes rather than a formal report.

Reporting and formal documentation: The policy emphasizes that these catheterization procedures are diagnostic and that the conduct and evaluation must be documented and interpreted by the physician in a formal report. For inpatient procedures, precertification/preauthorization is required; outpatient prior authorization requirements vary by product as specified in the policy.

Term	Definition
Right heart catheterization
Introduction of catheter(s) into right atrium, right ventricle and pulmonary artery including hemodynamic measurements and cardiac output determination; includes cannulation of the coronary sinus.
Left heart catheterization
Introduction of catheter(s) into the left ventricle (retrograde, transseptal, or transapical) including hemodynamic measurements, blood sampling and shunt determinations; may include left atrium and aorta catheterization.
Transseptal puncture
Technique using a catheter with enclosed puncture needle to puncture intact intra-atrial septum under imaging guidance to access left atrium; should not be billed if access via patent foramen ovale or ASD.

Medicare Determinations

name	number	type	effective date
Cardiac Catheterization and Coronary Angiography
L33557
LCD
2019-10-01

Revision History

2024-10-14added

New medical policy describing medically necessary and not medically necessary indications effective 2024-10-14.

2024-11-01revised

Updated link to Billing and Coding article A52850.

2025-08-??clarifiedLatest

Intracoronary ultrasound section clarified to remove statement that intravascular Doppler velocity and/or pressure-derived coronary flow reserve measurement may be medically necessary; codes 93571-93572 moved to MP 117 Percutaneous Coronary Intervention.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCardiac Catheterization and Angiography Policy

Policy CodePolicy 116

Change TypeClarified / Added / Revised

Effective DateOct 14, 2024

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if the procedure is performed inpatient; ensure medical necessity criteria are met and documented for listed CPT codes.

SourceLink

On This Page

Suspected cardiomyopathy or myocarditis.

Intracardiac shunts (including septal rupture) and extracardiac vascular shunts.

Endocarditis anticipated to require valvular surgical repair.

Suspected pericardial tamponade or constriction.

Suspected rejection of a transplanted heart.

Right Heart Catheterization - Not Medically Necessary

Right heart catheterization is NOT MEDICALLY NECESSARY for:

ANY of the following

Atherosclerotic heart disease without heart failure.

Left Heart Catheterization - Medically Necessary

Left heart catheterization is MEDICALLY NECESSARY for the diagnosis of, or treatment planning for:

ANY of the following

Myocardial abnormalities or dysfunction (including ischemic disease, myocarditis, cardiomyopathy).
Valvular dysfunction.
Congenital heart abnormalities.
Intracardiac shunts.
Cardiac trauma.
Pericardial tamponade.

Left Heart Catheterization by Transseptal Puncture - Medically Necessary

Transseptal catheterization may be considered MEDICALLY NECESSARY when retrograde arterial access is not feasible or appropriate and when:

ALL of the following

Access to the left ventricle is required for hemodynamic measurements or angiography when retrograde arterial access is not feasible or appropriate.
Access to the left atrium and pulmonary veins is necessary for hemodynamic measurements and angiography.
Access to the left atrium and ventricle is necessary for performance of diagnostic and therapeutic electrophysiological procedures.

Cardiac Angiography and Intracardiac Chamber Angiography - Medically Necessary

Angiograms of individual cardiac chambers are MEDICALLY NECESSARY for assessment of:

ANY of the following

Mitral or tricuspid valve function.
Ventricular function or morphology (including tumors and clots).
Intracardiac shunts.
Suspected ventricular aneurysms.
Congenital heart disease.
Cardiac trauma.

Coronary and Bypass Angiography - Medically Necessary

Coronary and bypass angiography are MEDICALLY NECESSARY for diagnosis or treatment planning for:

ANY of the following

Anginal syndromes.
Atypical chest pain suggesting ischemia.
Congenital heart disease.
Myocardial infarction.
Following cardiac arrest suspected to be due to ischemia or infarction.
Known atherosclerotic or other coronary disease.
Prinzmetal's angina.
Suspected graft or stent evaluation/closure.
Coronary shunts and fistulae.
Non-coronary cardiac surgical procedures when angiography is indicated.
Cardiac trauma.
Non-cardiac surgical procedures in high risk patients with evidence of ischemic heart disease.

Pulmonary Angiography - Medically Necessary

Pulmonary angiography is MEDICALLY NECESSARY for:

ANY of the following

Suspected pulmonary emboli.
Pulmonary hypertension.
Pulmonary artery stenosis.
Pulmonary arteriovenous malformations or shunts.
Congenital heart disease affecting the pulmonary vasculature including pulmonary venous return.

Intracoronary Ultrasound and Doppler/FFR Studies - Medically Necessary (conditional)

Intracoronary ultrasound may be considered MEDICALLY NECESSARY to:

ANY of the following

Assess the extent of coronary stenosis if equivocal on angiography.
Assess the patency and integrity of a coronary artery post-intervention.

Physiologic Exercise Study with Hemodynamic Measurement - Medically Necessary

Physiologic exercise hemodynamic testing is MEDICALLY NECESSARY when:

ALL of the following

Performed as a diagnostic test to evaluate cardiac abnormalities such as valve dysfunction, ventricular dysfunction or shunt ratios.
Includes pre-, intra- and post-exercise measurement of ventricular function (e.g., ejection fraction or wall motion) or hemodynamics.

Extra-Cardiac Angiography Performed with Cardiac Catheterization - Medically Necessary

Extra-cardiac angiography performed during the same session with cardiac catheterization is MEDICALLY NECESSARY for:

ANY of the following

Hypertensive heart and kidney disease.
Transient ischemic attack.
Atherosclerosis.
Aneurysm.
Artery dissection.
Embolism and thrombosis.

Endomyocardial Biopsy - Medically Necessary

Endomyocardial biopsy (CPT 93505) is MEDICALLY NECESSARY when medical necessity criteria are met.

ANY of the following

Indications include evaluation for suspected myocarditis and other clinical scenarios where biopsy is indicated.

Documentation Required

Medical necessity documentation

Medical necessity criteria in this policy must be met and documented for the listed CPT codes to be covered. Providers should report services using the most up-to-date procedure and diagnosis codes and include appropriate supporting clinical documentation.

Billing Rule

Extra-cardiac angiography code pairing requirement

When billing extra-cardiac angiography during the same encounter as cardiac catheterization, the specified extra-cardiac procedure code must be accompanied by the listed Column 2 and Column 3 cardiac catheterization procedure codes to be considered medically necessary.

75625 must be billed with Column 2 code 36140 and Column 3 code 93451
75630 must be billed with Column 2 code 36200 and Column 3 code 93453
75705 must be billed with Column 2 code 36215 and Column 3 code 93456
75710 must be billed with Column 2 code 36216 and Column 3 code 93457
75716 must be billed with Column 2 code 36217 and Column 3 code 93460