CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Minimally invasive coronary artery bypass graft surgery (CABG) — Coverage Criteria

Defines coverage determinations for minimally invasive CABG techniques (including MIDCAB, PACAB, TECAB, hybrid CABG) for Medicare Advantage and Commercial products offered by Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMinimally invasive coronary artery bypass graft surgery (CABG) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date12|07|2010

Next Review DateN/A

Key ActionVerify member benefits and eligibility with the provider call center and refer to the member's Benefit Booklet/Evidence of Coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medically necessaryMIDCAB stance

Not covered / NMNPACAB/TECAB/hybrid stance

S2205–S2209Covered HCPCS codes

CPT 33999Unlisted CPT

06|02|2021Last updated

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Coverage Determinations

Coverage determination by technique and product

Coverage determinations are product-specific (Medicare Advantage vs Commercial):

MIDCAB - Medicare Advantage & Commercial: Minimally invasive direct coronary artery bypass graft surgery (MIDCAB) may be considered medically necessary.

Covered HCPCS codes S2205–S2209 listed for MIDCAB.

PACAB/TECAB/Hybrid CABG - Medicare Advantage: Other techniques for minimally invasive coronary artery bypass graft surgery, including but not limited to port access coronary artery bypass (PACAB), hybrid coronary artery bypass graft (hybrid CABG), or total endoscopic coronary artery bypass (TECAB), are considered not covered for Medicare Advantage Plans.

Insufficient evidence to determine improved outcomes compared to conventional procedures.

PACAB/TECAB/Hybrid CABG - Commercial Products: Other techniques for minimally invasive coronary artery bypass graft surgery, including but not limited to PACAB, hybrid CABG, or TECAB, are considered not medically necessary for Commercial products.

Insufficient evidence to determine improved outcomes compared to conventional procedures.

For Medicare Advantage Plans and Commercial products, minimally invasive direct coronary artery bypass graft surgery (MIDCAB) may be considered medically necessary. In contrast, port-access coronary artery bypass (PACAB), total endoscopic coronary artery bypass (TECAB), and hybrid coronary artery bypass graft (hybrid CABG) techniques are not covered for Medicare Advantage Plans and are not medically necessary for Commercial products.

Other minimally invasive CABG techniques (including but not limited to PACAB, TECAB, or hybrid CABG) are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial products due to insufficient evidence that they improve outcomes compared to conventional CABG procedures.

Coding and Billing

Covered HCPCS Codes for MIDCABHCPCSCovered

S2205	Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini- sternotomy surgery, performed under direct vision; using arterial graft(s), single coronary arterial graft
S2206	Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two coronary arterial grafts
S2207	Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft
S2208	Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft
S2209	Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using two arterial grafts and single venous graft

Unlisted CPTCPT

33999

Unlisted procedure, heart; use for other minimally invasive CABG techniques when no specific CPT exists

Provider Actions and Operational Notes

Prior Authorization

Prior authorization is not applicable for this policy. Verify member benefits and prior auth requirements per the member's contract or benefit documents before scheduling services.

Prior Authorization: Not applicable

Denial Risk

Denial Risk — PACAB / TECAB / Hybrid CABG

For Medicare Advantage Plans and Commercial products, PACAB, TECAB, and hybrid CABG techniques are considered not covered or not medically necessary as noted below. Do not bill these techniques as covered procedures for the referenced products.

PACAB: Not covered for Medicare Advantage; Not medically necessary for Commercial
TECAB: Not covered for Medicare Advantage; Not medically necessary for Commercial
Hybrid CABG: Not covered for Medicare Advantage; Not medically necessary for Commercial

Background

Minimally invasive CABG encompasses different approaches. MIDCAB refers to direct approaches (for example, mini‑thoracotomy or mini‑sternotomy) performed under direct vision and is the technique the policy recognizes as potentially medically necessary. By contrast, endoscopic or port‑access approaches (PACAB/TECAB) and hybrid strategies combine surgical bypass with percutaneous coronary intervention; these approaches are not supported by sufficient evidence of improved outcomes relative to conventional CABG, which underlies the policy’s exclusion of PACAB, TECAB, and hybrid CABG for the stated products.

Definitions

MIDCAB — definition and brief description

TermMIDCAB (minimally invasive direct coronary artery bypass)

DefinitionMinimally invasive CABG performed under direct vision via mini-thoracotomy or mini-sternotomy, usually off-pump on a beating heart.

Typical technique/detailsPerformed without cardiopulmonary bypass by slowing the heart rate to ~40 bpm; commonly uses the internal mammary artery to bypass the left anterior descending (LAD) artery.

Anatomic targetsPrimarily LAD; bypass of the right coronary artery may be possible in select patients with suitable anatomy.

PACAB / TECAB — definition and brief description

TermPACAB / TECAB

Revision History

2010-12-07policy_effective

Policy effective date (original effective date recorded).

2021-06-02last_reviewLatest

Policy last reviewed with no material clinical policy statement changes noted.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMinimally invasive coronary artery bypass graft surgery (CABG) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date12|07|2010

Next Review DateN/A

Key ActionVerify member benefits and eligibility with the provider call center and refer to the member's Benefit Booklet/Evidence of Coverage.

SourceLink

On This Page

Note

Benefit and Eligibility Verification

Verify member eligibility and benefits prior to performing services. Benefits and coverage limitations vary by contract and the member's subscriber agreement or evidence of coverage controls.

Check Benefit Booklet / Evidence of Coverage / Subscriber Agreement
Contact provider call center for member-specific benefit information

Documentation Required

Provider Action — Coverage & Member Billing

Providers should refer to member documents for coverage determinations and may not balance-bill members for services determined to be not medically necessary unless the member was informed and provided written consent to pay privately in advance.

Do not charge member for non-covered or not medically necessary services unless documented written consent obtained in advance
Confirm coverage limits with the employer agreement or subscriber certificate

DefinitionPort-access coronary artery bypass (PACAB) and total endoscopic coronary artery bypass (TECAB) are endoscopic/port-access techniques where internal structures are visualized on a video monitor and the procedure is performed without direct visualization of the operative field.

Technical notesCardiopulmonary bypass may or may not be used; these techniques can theoretically access multiple coronary territories and may allow multivessel bypass.

Regulatory/technologySpecial instruments and robotic systems (e.g., da Vinci) have received FDA 510(k) clearance for assisting in minimally invasive CABG procedures.

Hybrid CABG — definition and brief description

TermHybrid CABG

DefinitionA combined approach that integrates minimally invasive surgical coronary bypass with percutaneous coronary intervention (PCI) as a hybrid strategy.

Evidence/coverage noteEvidence is insufficient to determine whether hybrid CABG improves outcomes compared to conventional procedures; policy treats hybrid CABG as not covered for Medicare Advantage and not medically necessary for Commercial products.