ModifiedPremera BluecrossPolicy N/A

Percutaneous coronary intervention (PCI)/Angioplasty in adults (emergent and non-emergent)

This policy governs when PCI/angioplasty is considered medically necessary for individuals aged 19 and older, specifying indications (acute coronary syndromes, post–cardiac arrest with presumed ischemia, significant left main or non-left-main coronary stenosis) and required conditions for coverage.

Policy Summary

PayerPremera Bluecross

PolicyPercutaneous coronary intervention (PCI)/Angioplasty in adults (emergent and non-emergent)

Policy CodePolicy N/A

Change TypeCoding additions and updatesnew policy effective date

Effective DateNov 7, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation demonstrating the medical necessity criteria (clinical indication, stenosis severity or abnormal FFR, and ability to tolerate dual antiplatelet therapy).

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944 and HCPCS codes C9600, C9601, C9602 and C9603 to match criteria following 90-day hold.

Added new CPT codes 92930, 92945 and notated CPT codes 92921, 92925, 92929, 92934, 92938, 92944 are termed. Added new HCPCS code C7569 and 7571; coding updates effective January 1, 2026.

This policy is a new policy approved July 8, 2025 effective November 7, 2025; PCI is considered medically necessary for select conditions when criteria are met.

Nov 7, 2025policy effective date

Jan 1, 2026effective date for latest coding updates

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Coverage and Medical Necessity Criteria

Medical Necessity Criteria

Covered when ALL of the following groups and their internal conditions are met as specified below

Primary covered indications

Acute coronary syndrome or related indications: Acute coronary syndrome indicated by one or more of: unstable angina (new onset, nocturnal, prolonged at rest, or progressive) OR myocardial infarction (NSTEMI or STEMI).
Post–cardiac arrest with presumed ischemia: Survivor of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia or ventricular fibrillation due to coronary artery disease amenable to PCI.
Significant left main coronary artery stenosis (requires all of the following): Anatomic left main stenosis ≥50% AND all of: anatomic conditions associated with low-to-intermediate PCI procedural risk and intermediate-to-high likelihood of good long-term outcome (e.g., SYNTAX score <33, bifurcation left main CAD); clinical characteristics predicting increased surgical risk (e.g., moderate–severe COPD, disability from prior stroke or cardiac surgery, STS-predicted operative mortality >2%); and individual able to tolerate dual antiplatelet therapy (e.g., clopidogrel and aspirin).left main ≥50%
Significant non-left-main coronary artery disease (requires all of the following): Significant non-left-main coronary stenosis (≥70% diameter stenosis by angiography OR fractional flow reserve (FFR) ≤ 0.80) in one or more vessels AND all of: revascularization is indicated by at least one of: unacceptable angina despite optimized medical therapy (therapeutic doses of at least 2 classes of antianginal medications) OR inability to implement optimized medical therapy because of absolute medication contraindication, clinically significant adverse effects, or other individual situation; stenosis amenable to PCI; and individual able to tolerate dual antiplatelet therapy (e.g., clopidogrel and aspirin).non-left-main ≥70% or FFR ≤0.80

Medically necessary indications (guided by cited professional society recommendations)

Covered when criteria and guideline-based indications are met

Guideline-based indications

Left main disease guidance: For significant left main disease, surgical revascularization is indicated to improve survival; percutaneous revascularization may be a reasonable option to improve survival in selected patients with low-to‑medium anatomic complexity (e.g., low or low–intermediate SYNTAX) when anatomy and clinical characteristics make PCI an appropriate alternative to surgery.
Stable ischemic heart disease and multivessel disease: In selected patients with multivessel disease (particularly with diabetes or high anatomic complexity), CABG may be preferred to improve survival; PCI may be reasonable when patients are poor surgical candidates or anatomy favors PCI. A Heart Team approach is recommended for complex decisions.
STEMI and nonculprit lesion strategy: Staged PCI of significantly stenosed nonculprit arteries in patients presenting with STEMI is recommended in select patients; immediate nonculprit PCI may be considered in stable patients with low-complexity disease but can be harmful in cardiogenic shock.

Not Medically Necessary

Not Medically Necessary: PCI is considered not medically necessary for individuals without a documented clinical indication that meets the medical necessity criteria in this policy.

Individuals who do not have a documented clinical indication that meets the policy’s medical necessity criteria are not eligible for coverage of PCI under this policy. The policy specifies required clinical presentations (for example, acute coronary syndromes, survivors of sudden cardiac arrest with presumed ischemia-mediated ventricular arrhythmia, or significant coronary stenosis meeting stated thresholds) and required supporting conditions (e.g., stenosis amenable to PCI, ability to tolerate dual antiplatelet therapy, and, for stable symptoms, failure of or inability to implement optimized medical therapy). When those elements are not documented, PCI is considered not medically necessary and may be denied.

For selected patients with stable ischemic heart disease, the policy cites guideline recommendations that performing PCI may be harmful or not recommended compared with CABG when coronary anatomy is unfavorable for PCI and the patient is a good candidate for CABG. In these situations, surgical revascularization (CABG) is the preferred option.

Percutaneous coronary intervention is considered not medically necessary when the clinical indication criteria in this policy are not met. The policy requires specific documented indications and supporting conditions (see medical necessity criteria) — absence of those elements is a basis for noncoverage.

The policy reiterates guideline-based guidance that PCI is not recommended (harm) for some patients with stable ischemic heart disease who have anatomy unfavorable for PCI when they are good candidates for CABG. In these cases, CABG should generally be favored over PCI.

CPT and HCPCS Codes; Definitions for Significance

Covered CPT Codes (selected list)CPTCovered

92920

Percutaneous transluminal coronary angioplasty; single major coronary artery or branch

Covered CPT/HCPCS Codes (expanded)mixedCovered

92921	Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92924	Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery and/or its branch(es).
92925	Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92928	Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery and/or its branch(es); 1 lesion involving 1 or more coronary segments.
92929	Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92930	Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 2 or more distinct coronary lesions with 2 or more coronary stents deployed in 2 or more coronary segments, or a bifurcation lesion requiring angioplasty and/or stenting in both the main artery and the side branch (new code effective 01/01/26).
92933	Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery and/or its branch(es).
92934	Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure).
92937	Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed, single major coronary artery and/or its branch(es).
92938	Percutaneous transluminal revascularization of or through coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure).

1–10 of 20

1/2

Covered CPT Codes (added/updated)CPTCovered

92920	CPT code added to policy
92921	CPT code added to policy (later termed)
92924	CPT code added to policy
92925	CPT code added to policy (later termed)
92928	CPT code added to policy
92929	CPT code added to policy (later termed)
92933	CPT code added to policy
92934	CPT code added to policy (later termed)
92937	CPT code added to policy
92938	CPT code added to policy (later termed)

1–10 of 15

1/2

Covered HCPCS Codes (added/updated)HCPCSCovered

C9600	HCPCS code added to policy
C9601	HCPCS code added to policy
C9602	HCPCS code added to policy
C9603	HCPCS code added to policy
C7569	HCPCS code added (effective Jan 1, 2026)
7571	HCPCS code added (effective Jan 1, 2026)

Significant stenosis definitions

Left main stenosisDefined as ≥50% luminal diameter narrowing by visual assessment on angiography

Non–left‑main (epicardial) stenosisDefined as ≥70% luminal diameter narrowing by visual assessment on angiography

Physiologic assessment (FFR)FFR ≤ 0.80 is considered abnormal and indicates physiologic significance of a stenosis

Significant coronary stenosis thresholds

Epicardial (non‑left‑main) threshold≥70% luminal diameter narrowing by visual assessment on angiography

Left main threshold

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for the listed PCI/CPT and HCPCS codes. Providers must submit documentation supporting the medical necessity of the procedure before authorization will be approved.

Affected codes include CPT 92920, 92921, 92924, 92925, 92928, 92929, 92930, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92945 and HCPCS C7569, C7571, C9600, C9601, C9602, C9603
Prior authorization decisions will reference the coding listed in the policy and require clinical documentation to demonstrate criteria are met

Billing Rule

Coding Reference for Authorization

Prior authorization and coding determinations should reference the CPT and HCPCS codes listed in this policy. Claims for services using these codes may be denied if the submitted documentation does not demonstrate that medical necessity criteria are met.

Background and Clinical Context

Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a non‑surgical procedure used to open narrowed coronary arteries to restore blood flow and relieve ischemic symptoms. PCI techniques include balloon angioplasty, placement of intracoronary stents, and adjunctive plaque modification such as atherectomy; the procedure may be performed emergently (for acute coronary syndromes) or electively for symptomatic coronary disease. Alternatives to PCI include optimal medical therapy and surgical revascularization (CABG); clinical evidence and guidelines referenced in the policy emphasize that PCI provides symptomatic relief and that selection between medical therapy, PCI, and CABG depends on anatomy, clinical presentation, physiologic testing (for example, fractional flow reserve), and patient surgical risk.

Scoring Systems and Term Definitions

SYNTAX Score

DefinitionSYNTAX Score quantifies coronary anatomic complexity based on lesion number, occlusion, bifurcation/trifurcation, ostial disease, lesion length, tortuosity, and calcification

Clinical roleHigher SYNTAX scores indicate greater anatomic complexity and correlate with higher PCI-related morbidity and mortality

Policy applicationUsed to assess anatomic complexity when considering PCI for left main or multivessel disease (examples: low-intermediate SYNTAX <33 may favor PCI in select patients)

STS Risk Score

DefinitionSTS Risk Score predicts likelihood of postoperative mortality and complications after cardiac surgery using clinical and cardiac-specific variables

ComponentsIncludes factors such as age, comorbidities (e.g., peripheral vascular disease, diabetes), valvular disease, heart failure, and recent MI

Policy Changes and Effective Dates

2015-06-17annual_review

Annual review; no changes to policy statements; ICD-9 and ICD-10 diagnosis and procedure codes removed and select HCPCS codes removed from coding list.

2025-07-08policy_approval_new_policy

New policy approved establishing PCI coverage criteria; policy effective for dates of service on or after 2025-11-07 following a 90-day provider notification period.

2025-08-01policy_publication

Policy Summary

PayerPremera Bluecross

PolicyPercutaneous coronary intervention (PCI)/Angioplasty in adults (emergent and non-emergent)

Policy CodePolicy N/A

Change TypeCoding additions and updatesnew policy effective date

Effective DateNov 7, 2025

Next Review DateN/A

SourceLink

On This Page

Step Therapy

Step Therapy / Medical Therapy Requirement

Step therapy is not explicitly required by this policy; however, for stable ischemic heart disease, the individual must have optimized medical therapy or documented unacceptable angina before PCI is considered medically necessary.

Optimized medical therapy typically includes therapeutic doses of at least two classes of antianginal medications unless contraindicated or not tolerated
If optimal medical therapy cannot be implemented due to contraindication, adverse effects, or other individual circumstances, document the reason(s)

Documentation Required

Required Documentation to Support Medical Necessity

Documentation supporting medical necessity must be submitted with prior authorization requests and should be present in the medical record for claims review. Lack of adequate documentation is a denial risk.

Indication for PCI (e.g., acute myocardial infarction, unstable angina, stable ischemic heart disease with unacceptable angina)
Symptoms and clinical presentation (chest pain characterization, ischemic equivalents, hemodynamic instability if applicable)
Objective evidence of ischemia when applicable (eg, abnormal noninvasive stress testing, FFR results ≤80, imaging evidence)
Anatomic documentation of stenosis and severity (angiographic percent diameter stenosis with vessel and lesion location; left main ≥50% or non-left-main ≥70% threshold unless supported by abnormal FFR or other physiologic testing)
Documentation that stenosis is technically amenable to PCI
Prior medical therapy details (agents, doses, duration) and documentation of optimization or contraindications/intolerance to therapy
Ability to tolerate dual antiplatelet therapy
Relevant risk scores or multidisciplinary recommendations when applicable (eg, SYNTAX score, STS predicted operative mortality, Heart Team discussion for complex or multivessel disease)
For survivors of sudden cardiac death with presumed ischemia-mediated ventricular arrhythmia, documentation that CAD is amenable to PCI

Documentation Required

Required Clinical Documentation

Clinical documentation must support the presence of a significant coronary stenosis and other criteria for revascularization. Failure to document thresholds or supporting physiologic data may result in the procedure being considered not medically necessary.

Significant stenosis thresholds: ≥70% diameter narrowing for epicardial coronary stenosis; ≥50% for left main stenosis by angiography; 40–70% with abnormal FFR supports significance
FFR ≤80 defined as abnormal and consistent with inducible ischemia (document FFR value and interpretation)
When percent stenosis is borderline, provide physiologic testing (FFR, iFR) or noninvasive ischemia evidence to substantiate revascularization
Document anatomic details (vessel, segment, lesion count), previous interventions, and whether the lesion is de novo or in a bypass graft
If left main or multivessel disease is present, provide risk stratification and rationale for PCI versus CABG (including Heart Team input when applicable)

Denial Risk

Denial Risk and Triggers

Denial triggers — PCI will be considered not medically necessary and may be denied when criteria are not met or required documentation is absent.

No documented clinical indication meeting the policy’s medical necessity criteria
No objective evidence of significant stenosis or lack of physiologic testing when stenosis is borderline
Insufficient documentation of optimized medical therapy or a documented reason why it cannot be used in stable patients
Inability to demonstrate the individual can tolerate dual antiplatelet therapy when required