CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Surgical Ventricular Restoration

This Commercial Products policy from Blue Cross Blue Shield of Rhode Island defines coverage for surgical ventricular restoration (SVR) procedures for patients with ischemic dilated cardiomyopathy; it applies to Commercial Products only and references separate guidance for Medicare Advantage Plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySurgical Ventricular Restoration

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2017

Next Review Date

Key ActionVerify member-specific benefits and eligibility against the Benefit Booklet, Evidence of Coverage, Subscriber Agreement or employer agreement as benefits may vary between groups and contracts.

SourceLink

POLICY UPDATE CHANGES

There are no material clinical or coverage changes for this policy.

1CPT codes listed as not medically necessary

CommercialScope: Commercial only

Coverage Summary

This policy defines coverage for surgical ventricular restoration (SVR) procedures for patients with ischemic dilated cardiomyopathy and applies to Commercial Products only; separate guidance is referenced for Medicare Advantage Plans. The policy effective date is 05|01|2017 and the policy was last reviewed on 04|20|2022.

Medical Necessity / Coverage Determinations

Commercial Products Coverage Determination

SVR is considered not medically necessary for Commercial Products:

Commercial Products Coverage Determination: Surgical ventricular restoration is considered not medically necessary as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Prior Authorization

Prior authorization applicability:

Prior authorization: Not applicable.

Medicare Advantage Plans

Applicability statement:

Medicare Advantage Plans: This policy is applicable to Commercial Products only; for Medicare Advantage Plans, see Related Policies section for National and Local Coverage Determinations.

Coding

Not Medically Necessary CPT codesCPTNot Covered

33548

Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures)

Billing Rule

Do not bill as medically necessary for Commercial Products

CPT 33548 is designated not medically necessary for Commercial Products and should not be billed as a covered service under this policy.

33548

Provider Actions

Documentation Required

Benefit verification

Verify member-specific benefits and eligibility against the Benefit Booklet, Evidence of Coverage, Subscriber Agreement or employer agreement as benefits may vary between groups and contracts.

Note

Prior Authorization

Prior authorization: Not applicable.

Background & Evidence

Surgical ventricular restoration (SVR) is performed to restore or remodel the left ventricle to a more normal shape and size in patients with akinetic segments from ischemic dilated cardiomyopathy. Techniques include endoventricular circular plasty, the Dor procedure, SAVER, use of circular 'purse string' suturing around scar borders, and patch reconstruction when defects are large; SVR is frequently performed in conjunction with coronary artery bypass grafting (CABG).

Randomized and uncontrolled studies have evaluated SVR added to CABG. The large randomized Surgical Treatment of Ischemic Heart Failure (STICH) trial did not show significant improvements in quality of life for patients receiving SVR as an adjunct to CABG, and while several uncontrolled studies reported hemodynamic or functional improvements in selected patients, the totality of evidence was judged insufficient to demonstrate an improvement in net health outcome. Consequently, SVR (CPT 33548) is listed as not medically necessary for Commercial Products.

Definitions

Evidence / Regulatory Notes

Name	Number	Type	Effective Date
Partial Ventriculectomy	20.26	NCD
Source	CMS NCD 20.26