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ModifiedCurativePolicy CHP-IP-2026-167

Cardiac Tumor Excision (Including Atrial Myxoma)

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Inpatient medical-necessity criteria for surgical excision of primary intracardiac tumors, including atrial myxoma, papillary fibroelastoma, and selected malignant or metastatic cardiac tumors, for Curative commercial PPO and EPO members; thrombus, vegetation management, and pericardial disease are out of scope.

Policy Summary

PayerCurative

PolicyCardiac Tumor Excision (Including Atrial Myxoma)

Policy CodePolicy CHP-IP-2026-167

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionSubmit tumor imaging, symptoms or embolic/obstructive events, tumor-board recommendations when applicable, ASA status, comorbidities, operative information, and level-of-care documentation with inpatient requests.

SourceLink

POLICY UPDATE CHANGES

Clinical indications now distinguish prompt excision of myxomas from excision of fibroelastomas based on left-sided location, mobility, symptoms, or embolic events.

The policy clarifies that the Medicare two-midnight benchmark and CMS inpatient-only list are not commercial coverage criteria.

Prompt excisionMyxoma management

Left-sided/mobileFibroelastoma excision features

92%Discharge oxygenation

100 mL/hourICU chest-tube threshold

24 hoursHemodynamic stability before discharge

Every 48 hoursConcurrent review

Inpatient Cardiac Tumor Excision Criteria

Initial inpatient admission

Covered when ALL of the following are met.

Inpatient admission

Procedure indication
- Myxoma imaging: Intracardiac mass has imaging features of myxoma on echocardiography and/or cardiac MRI.
- Benign tumor risk: Papillary fibroelastoma or another benign tumor is left-sided and mobile, has caused embolism, or causes valve dysfunction or obstruction.
- Malignant or metastatic tumor: A multidisciplinary tumor board recommends resection for cure, local control, or relief of obstruction.

Policy Summary

PayerCurative

PolicyCardiac Tumor Excision (Including Atrial Myxoma)

Policy CodePolicy CHP-IP-2026-167

Change TypeModified

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Uncertain intracardiac mass: Tissue diagnosis is needed and less invasive biopsy is not feasible.

Inpatient setting required

Open cardiac procedure or bypass: Open cardiac procedure with sternotomy or thoracotomy, or cardiopulmonary bypass, requires planned postoperative cardiac ICU care with invasive hemodynamic monitoring.
Expected postoperative support: Expected need for postoperative mechanical ventilation, vasoactive or inotropic infusion, temporary pacing, or mechanical circulatory support.
High risk or comorbidity: ASA physical status III or IV, or a comorbidity requires postoperative monitoring or management beyond ambulatory or observation care, such as heart failure, chronic kidney disease, poorly controlled diabetes, obstructive sleep apnea on therapy, or anticoagulation bridging.ASA III or IV

Observation or outpatient alternatives

These services are handled outside inpatient tumor-excision admission when the stated circumstances apply.

Outpatient diagnostic or surveillance care: Diagnostic imaging, staging, and surveillance of a small, immobile, right-sided fibroelastoma or lipoma without symptoms are outpatient services.

Stroke admission pathway: Embolic stroke from a known myxoma is admitted under the stroke or medical policy, with expedited tumor excision when neurologically appropriate.

ICU placement

ICU placement is appropriate when ANY of the following is present.

ICU level of care

Immediate postoperative period after cardiac surgery until extubated and hemodynamically stable, commonly the first 12 to 24 hours.12–24 hours commonly
Advanced support: Vasoactive or inotropic infusion, mechanical circulatory support including intra-aortic balloon pump, microaxial pump, or ECMO, or an open chest is present.
Bleeding: Mediastinal chest-tube output exceeds 100 mL per hour for 2 consecutive hours, or bleeding requires transfusion of more than 2 units in 4 hours or re-exploration.>100 mL/hour for 2 hours; >2 units/4 hours
Ventilatory, rhythm, or neurologic instability: Mechanical ventilation, a new arrhythmia requiring titrated intravenous therapy, or an acute neurologic deficit is present.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY criterion is present and no ICU criterion is met.

Post-extubation monitoring: Patient is extubated and off vasoactive infusions, or on a single low-dose agent being weaned, with continuous telemetry required.
Pacing or atrial fibrillation: Temporary epicardial pacing wires are in use or new atrial fibrillation is being controlled.
Chest-tube monitoring: Chest tubes remain in place with ongoing drainage monitoring.

Medical-surgical placement

Medical-surgical placement is appropriate when ANY criterion is present and no higher-level criterion is met.

Medical-surgical unit

Stable recovery: Patient is hemodynamically stable on oral medications, chest tubes are removed or output is minimal, pacing is not required, and progressive mobility is underway.
Lower-acuity postoperative management: Ongoing diuresis, anticoagulation initiation, or cardiac rehabilitation teaching is required before discharge.

Discharge readiness

Discharge from acute inpatient care is appropriate when ALL of the following are met.

Hemodynamic and temperature stability: Hemodynamically stable for at least 24 hours without intravenous vasoactive agents, and temperature is below 38.0°C for at least 24 hours or a fever source has been identified and treated.24 hours; <38.0°C
Oxygenation: SpO2 is at least 92% on room air or the patient's baseline home oxygen.>=92%
Basic recovery functions: Pain is controlled on an oral regimen, oral diet is tolerated or a stable enteral or parenteral plan is in place, and the patient is voiding.
Mobility or post-acute placement: Patient is ambulating at the expected post-procedure level or a skilled post-acute setting is arranged.
Wound and drains: Wound is clean without signs of deep infection, and drains are removed or a home drain-care plan is in place.
Laboratory stability: Hemoglobin, creatinine, and electrolytes are stable.
Medication and follow-up planning: Medication reconciliation is completed, including venous thromboembolism prophylaxis and any anticoagulation plan, and surgeon follow-up is arranged, commonly within 7 to 14 days.7–14 days commonly
Pathology and surveillance: Pathology is reviewed or pending with a follow-up plan, and surveillance echocardiography is scheduled.

Continued-stay criteria

Continued acute inpatient stay is medically necessary when ANY of the following is documented at concurrent review.

Continued acute stay

Instability or support: Hemodynamic or respiratory instability, or ongoing need for intravenous vasoactive agents, ventilation, or supplemental oxygen above baseline that cannot be provided at a lower level.
Postoperative complication: A postoperative complication requiring acute hospital treatment is present, including bleeding, infection, arrhythmia, venous thromboembolism, acute kidney injury, ileus, or delirium.
Intravenous treatment: Intravenous medications, fluids, or nutrition cannot be given safely at a lower level of care.
Urgent inpatient service pending: An urgent procedure or imaging study requiring inpatient status is pending.

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review.

Low-risk asymptomatic tumor: Small, immobile, asymptomatic right-sided papillary fibroelastoma or cardiac lipoma without symptoms, obstruction, or arrhythmia; surveillance is reasonable.
DNM-1
Convenience pre-admission: Admission the day before surgery solely for testing, bowel preparation, or convenience when no medical optimization is required; same-day admission is standard.
DNM-2
Post-discharge-ready stay: Continued postoperative stay after all discharge-readiness criteria are met.
DNM-3
Awaiting placement only: Continued acute inpatient days solely while awaiting skilled nursing, rehabilitation, long-term acute care, behavioral health, or home-service placement after discharge readiness is met and no acute hospital-level service is delivered.
DNM-4; authorized days are not retroactively denied.
Custodial or convenience care: Days used for custodial care, family or provider convenience, or scheduling non-urgent tests or consultations that could safely occur at a lower level or after discharge.
DNM-5

Tumor-specific clinical indications

Clinical indications for excision vary by tumor type.

Myxoma: Prompt excision is indicated because of embolic and obstructive risk.

Fibroelastoma: Excision is indicated when the fibroelastoma is left-sided and mobile, symptomatic, or associated with an embolic event.

The source wording identifies left-sided and mobile, symptomatic, or embolic features; it does not specify whether these are separate alternatives or combined requirements.

Malignant cardiac tumor: Multidisciplinary planning is required for malignant cardiac tumors.

NCCN sarcoma guidelines may be cited by name and recommendation category.

Concurrent and partial authorization review

Concurrent review applies to each continued-stay period.

Continued-stay review: Each continued-stay period is subject to concurrent review, with approval limited to the portion supported by documentation when requested quantity, units, or duration exceed support.

Days already authorized are not retroactively denied, and expected length of stay is a planning benchmark rather than a limit on covered days.

This policy does not address thrombus or vegetation management or pericardial disease. Pericardial disease is addressed under related policy F039.

Open cardiac tumor excision is not considered an observation or outpatient procedure. Diagnostic imaging, staging, and surveillance for small, immobile, right-sided fibroelastomas or lipomas without symptoms may be performed outpatient; embolic stroke from a known myxoma follows the stroke or medical admission pathway, with expedited tumor excision when neurologically appropriate.

Excision of a small, immobile, asymptomatic right-sided papillary fibroelastoma or cardiac lipoma does not meet medical-necessity criteria when there are no symptoms, obstruction, or arrhythmia. Surveillance is reasonable, and the request is referred for physician review.

A pre-operative admission the day before surgery solely for testing, bowel preparation, or convenience does not meet criteria when no medical optimization is required, such as intravenous-heparin bridging, heart-failure optimization, or dialysis. Same-day admission is standard.

Continued acute inpatient days after all discharge-readiness criteria are met do not meet acute-level medical-necessity criteria. This includes days used solely while awaiting skilled nursing, rehabilitation, long-term acute care, behavioral-health, or home-service placement, as well as custodial care, family or provider convenience, or non-urgent services that could safely occur at a lower level of care or after discharge. Days already authorized are not retroactively denied.

Coding and Utilization Reference

ICD-10-CMICD-10

D15.1	Benign neoplasm of heart
C38.0	Malignant neoplasm of heart

ICD-10-PCS open cardiac excisionICD-10

02B70ZZ	Excision of atrial septum, open
02BK0ZZ	Excision of right atrium, open
02BL0ZZ	Excision of left atrium, open
02B50ZZ	Excision of right ventricle, open
02B60ZZ	Excision of left ventricle, open

CPTCPT

33120	Intracardiac tumor excision with bypass
33130	External cardiac tumor resection

MS-DRG FY 2027 v44mixed

219	MS-DRG 219
220	MS-DRG 220
221	MS-DRG 221
228	MS-DRG 228
229	MS-DRG 229

Revenue codesRevenue

0200	Revenue code 0200
0206	Revenue code 0206
0360	Revenue code 0360
0370	Revenue code 0370

Mediastinal chest-tube output

ICU placement thresholdMediastinal chest-tube output above 100 mL per hour for 2 consecutive hours supports ICU placement.

Clinical significanceThe threshold is listed under ICU-level-of-care criteria after cardiac surgery.

Alternative bleeding criterionBleeding requiring transfusion of more than 2 units in 4 hours or re-exploration also supports ICU placement.

Bleeding transfusion threshold

Transfusion thresholdBleeding requiring transfusion of more than 2 units in 4 hours supports ICU placement.

Re-exploration thresholdBleeding requiring surgical re-exploration supports ICU placement.

Related chest-tube thresholdMediastinal chest-tube output above 100 mL per hour for 2 consecutive hours also supports ICU placement.

Discharge hemodynamic stability

Required stability periodThe patient must be hemodynamically stable for at least 24 hours.

Intravenous vasoactive agentsThe 24-hour stability period must occur without intravenous vasoactive agents.

Discharge readinessThis is one of the requirements for discharge from acute inpatient care.

Discharge temperature

Temperature thresholdTemperature must remain below 38.0°C for at least 24 hours.

Alternative pathwayDischarge readiness may be met when a fever source has been identified and treated.

Discharge requirementTemperature stability is required together with hemodynamic stability for discharge from acute inpatient care.

Discharge oxygenation

Minimum oxygen saturationSpO2 must be 92% or higher.

Room-air conditionThe minimum SpO2 applies on room air.

Home-oxygen alternativeThe requirement may also be met on the patient's baseline home oxygen.

FY 2027 length-of-stay benchmarks

DRGs 219, 220, and 221FY 2027 geometric mean length-of-stay benchmarks are 8.0, 5.3, and 2.5 days, respectively.

DRGs 228-229FY 2027 geometric mean length-of-stay benchmarks are 5.9 and 2.5 days, respectively.

Use of benchmarksThese figures are planning benchmarks only and are not limits on covered days.

Authorization and Documentation Requirements

Prior Authorization

Submit Inpatient Medical-Necessity Request

Submit an inpatient medical-necessity request for cardiac tumor excision. Include documentation that a qualifying tumor indication is present and that inpatient care is required, such as open cardiac surgery with planned ICU monitoring, expected mechanical ventilation or vasoactive/inotropic support, or ASA III/IV status or comorbidity requiring management beyond observation or ambulatory care.

Documentation Required

Include Supporting Clinical Records

Include the supporting clinical records needed to evaluate the tumor indication, inpatient level of care, operative course, continued stay, and discharge plan.

Echocardiography, cardiac MRI or CT findings, and relevant clinical symptoms
Tumor-board recommendation when malignancy is present
ASA status, comorbidities, operative documentation, daily progress notes, and discharge planning records

Documentation Required

Document Tumor Imaging and Anatomy

Provide transthoracic and transesophageal echocardiography and cardiac MRI or CT findings describing the tumor’s location, size, mobility, and attachment.

Documentation Required

Document Clinical Manifestations

Document embolic or obstructive events and constitutional symptoms relevant to the cardiac tumor.

Include evidence of embolism, obstruction, valve dysfunction, or constitutional manifestations when applicable.

Documentation Required

Submit Malignancy Treatment Recommendation

For a malignant primary or metastatic cardiac tumor, submit the multidisciplinary tumor-board recommendation for resection for cure, local control, or relief of obstruction.

Identify the applicable multidisciplinary planning recommendation.
Cite the applicable NCCN sarcoma guideline by name and recommendation category when used.

Documentation Required

Document Risk and Comorbidities

Provide the patient’s ASA physical status and relevant comorbidities to support the risk assessment and inpatient level-of-care decision.

Identify ASA III or IV status when applicable.
Describe comorbidities requiring postoperative monitoring or management beyond ambulatory or observation care, such as heart failure, chronic kidney disease, poorly controlled diabetes, obstructive sleep apnea on therapy, or anticoagulation bridging.

Documentation Required

Submit Operative Documentation

Submit the operative note documenting the surgical approach and any intraoperative events.

Include whether sternotomy, thoracotomy, cardiopulmonary bypass, or another approach was used.
Record clinically relevant intraoperative complications or events.

Documentation Required

Support Concurrent Review

For concurrent review, submit daily ICU progress notes or progress notes at least every 48 hours on other units supporting the level of care, complications, and reason for continued stay when the expected length of stay is exceeded.

Document hemodynamic or respiratory instability, acute complications, intravenous treatment needs, or an urgent inpatient procedure or imaging requirement.
Expected length of stay is a planning benchmark, not a limit on covered days.

Documentation Required

Document Discharge Planning

Provide a discharge-readiness assessment and post-acute plan, including the services and setting needed after acute inpatient care.

Address readiness for discharge and any planned skilled nursing, rehabilitation, long-term acute care, behavioral health, home services, or other post-acute support.

Documentation Required

Document Malignant Tumor Planning

For malignant cardiac tumors, document multidisciplinary treatment planning and identify the applicable NCCN guideline version, including the relevant recommendation category when cited.

Explain how the tumor-board recommendation supports resection for cure, local control, or relief of obstruction.

Documentation Required

Support Requested Amount and Duration

Document the requested quantity, units, and duration, particularly when the request exceeds the standard or expected amount. Explain the clinical basis for each requested increment.

Support any extended inpatient duration with concurrent-review documentation and the applicable continued-stay rationale.
An expected length of stay is a planning benchmark, not a coverage limit.

Denial Risk

Asymptomatic Low-Risk Right-Sided Tumor

Requests for excision of a small, immobile, asymptomatic right-sided papillary fibroelastoma or cardiac lipoma without symptoms, obstruction, or arrhythmia do not meet automated medical-necessity criteria. Surveillance may be reasonable, and the request must be referred for physician review.

Document symptoms, embolic risk, obstruction, mobility, or arrhythmia when present.
Do not rely on automated or non-physician denial for this scenario.

Denial Risk

Avoid Convenience or Discharge-Ready Inpatient Days

Avoid preoperative inpatient admission solely for testing, bowel preparation, or convenience; same-day admission is standard when no medical optimization is required. Continued inpatient days after all discharge-readiness criteria are met, including days awaiting placement or post-acute services without acute hospital-level care, are not medically necessary.

Document necessary medical optimization, such as intravenous heparin bridging, heart-failure optimization, or dialysis, when applicable.
Use active discharge planning; days already authorized are not retroactively denied.

Denial Risk

Support Continued Inpatient Stay

Support every continued-stay period with at least one acute inpatient need documented at concurrent review. Continued stay requires instability, an acute postoperative complication, intravenous treatment that cannot safely be provided at a lower level, or a pending urgent inpatient procedure or imaging study.

Examples include hemodynamic or respiratory instability, above-baseline oxygen, bleeding, infection, arrhythmia, venous thromboembolism, acute kidney injury, ileus, delirium, or non-deferrable intravenous medications, fluids, or nutrition.

Note

Criteria Not Met: Physician Review Required

If criteria are not met, the request is referred for physician review. Only a licensed physician of the same or similar specialty may issue an adverse determination, and the requesting provider must be offered a peer-to-peer discussion.

Automated systems and non-physician clinical reviewers may approve in full or in part but may not issue an adverse determination.

Billing Rule

Unsupported Quantity or Duration

When documentation supports only part of the requested quantity, units, or duration, approve the supported portion and review only the unsupported increment. Provide documentation explaining the clinical basis for the requested excess.

Previously authorized days are not retroactively denied.
The absence of a specifically stated criterion is not by itself a basis for adverse determination; physician review applies generally accepted standards of medical practice.

Clinical Background

Most primary cardiac tumors are benign; important types include atrial myxoma, papillary fibroelastoma, lipoma, and malignant tumors such as sarcoma. Atrial myxomas may cause embolism, mitral inflow obstruction, and constitutional symptoms. Left-sided, mobile papillary fibroelastomas carry embolic risk, particularly when symptoms or an embolic event is present, and prompt excision is generally recommended in those circumstances. Malignant primary and metastatic tumors require multidisciplinary planning, with resection considered when cure, local control, or relief of obstruction is feasible.

Policy Definitions

Primary cardiac tumor

DefinitionA primary cardiac tumor is a tumor arising from cardiac tissue.

Benign examplesRepresentative examples include myxoma, papillary fibroelastoma, and lipoma.

Malignant exampleSarcoma is another representative example of a primary cardiac tumor.

Expected length of stay

DefinitionExpected length of stay is a planning benchmark for an uncomplicated course.

Clinical useIt provides a benchmark for planning an uncomplicated inpatient course.

Coverage implicationIt is not a limit on covered days.