Currentpriority healthPolicy N/A

Transcatheter Closure of Septal Defects

Policy governing medical necessity and coverage criteria for transcatheter closure of intracardiac septal defects (ASD, PDA, Fontan fenestration, VSD) and PFO for cryptogenic stroke for Priority Health members; applies to insured product lines as specified.

Policy Summary

Payerpriority health

PolicyTranscatheter Closure of Septal Defects

Policy CodePolicy N/A

Change TypeRevised — indication added

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionIf prior authorization is required, submit medical necessity documentation to Priority Health per the Provider Manual.

SourceLink

POLICY UPDATE CHANGES

Ventricular septal defects is no longer an exclusion and has been added as an indication for transcatheter closure.

4listed medically necessary septal defect indications

1PFO indication tied to failed antithrombotic therapy

2CPT codes listed as covered

2HCPCS implant/occlusion device codes listed

Coverage and Medical Necessity Criteria

Policy Summary

Payerpriority health

PolicyTranscatheter Closure of Septal Defects

Policy CodePolicy N/A

Change TypeRevised — indication added

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionIf prior authorization is required, submit medical necessity documentation to Priority Health per the Provider Manual.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PFO Closure

Transcatheter closure of patent foramen ovale (PFO) may be considered medically necessary when ALL of the following are met:

PFO closure for presumed paradoxical embolism: History of cryptogenic stroke, transient ischemic attack, or arterial embolism due to presumed paradoxical embolism through the PFO; AND conventional drug therapy (one or more antithrombotics) has failed prior to device closure; AND the device is FDA approved and used as labeled (e.g., Amplatzer PFO Occluder).

Not Medically Necessary

Transcatheter closure of septal defects is considered not medically necessary for all other indications including, but not limited to:

Not medically necessary conditions: Multiple defects that cannot be adequately covered by the device; Associated congenital cardiac anomalies that require cardiac surgery; Ostium primum atrial septal defects; Sinus venosus atrial septal defects; Partial anomalous pulmonary venous drainage; Pulmonary hypertension; Congestive heart failure; Sepsis; Coagulation disorders in patients who are unable to take antiplatelet or anticoagulant therapy; Migraine prophylaxis.

These conditions are listed explicitly as exclusions and may lead to denial of coverage.

Use of transcatheter septal occlusion devices for indications not listed as medically necessary is considered not medically necessary and may be denied. Explicit examples include migraine prophylaxis and the anatomic or physiologic conditions listed in the policy: multiple defects not amenable to device coverage, associated congenital cardiac anomalies requiring surgical repair, ostium primum or sinus venosus ASDs, partial anomalous pulmonary venous drainage, pulmonary hypertension, congestive heart failure, sepsis, and coagulation disorders that preclude antiplatelet or anticoagulant therapy. Providers should ensure the indication for device placement matches one of the policy's listed medically necessary indications before requesting authorization.

Percutaneous transcatheter closure of a congenital ventricular septal defect with implant is listed in the coding section as not covered (CPT 93581) and claims for unlisted septal defect procedures (e.g., 93799) require explanatory notes with the claim. Note that the body of the policy text identifies ventricular septal defects among the medically necessary indications; however, the coding table explicitly lists CPT 93581 as not covered. When billing, submit the appropriate covered CPT or, if using an unlisted code, include detailed explanatory documentation per claim requirements.

Billing and Coding

Covered CPT CodesCPTCovered

93580	Percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant
93582	Percutaneous transcatheter closure of patent ductus arteriosus

Not CoveredCPTNot Covered

93581	Percutaneous transcatheter closure of a congenital ventricular septal defect with implant
93799	Unlisted cardiovascular service or procedure septal defect procedure - explanatory notes must accompany claim

HCPCS Codes (Implants/Devices)HCPCS

C1817	Septal defect implant system, intracardiac
C2628	Catheter, occlusion

ICD-10 Codes that may applyICD-10

G45.0-G45.9	Transient cerebral ischemic attacks and related syndromes
I23.1	Atrial septal defect as current complication following acute myocardial infarction
I51.0	Cardiac septal defect, acquired
I63.9	Cerebral infarction, unspecified
Q21.10-Q21.19	Atrial septal defect
Q21.20-Q21.23	Atrioventricular septal defect
Q25.0	Patent ductus arteriosus

Provider Requirements and Operational Notes

Prior Authorization

Prior authorization may be required

Prior authorization may be required for this procedure per product; when required submit medical necessity documentation to Priority Health.

Step Therapy

Antithrombotic therapy must fail before PFO device closure

For PFO closure, conventional drug therapy (one or more antithrombotics) must have failed prior to device closure; the device must be FDA approved and used as labeled (e.g., Amplatzer PFO Occluder).

Documentation Required

Submit PA request with medical necessity documentation

If prior authorization is required by the product, providers must submit a request demonstrating medical necessity per the Priority Health Provider Manual and include applicable documentation as required by the member's plan.

Denial Risk

Denial risk for indications outside the policy

Procedures for indications other than the listed medically necessary ones are considered not medically necessary and may be denied.

Examples include migraine prophylaxis; multiple defects not amenable to device coverage; associated anomalies requiring surgery; ostium primum or sinus venosus ASDs; partial anomalous pulmonary venous drainage; pulmonary hypertension; congestive heart failure; sepsis; or coagulation disorders preventing antiplatelet/anticoagulant therapy.

Background

Transcatheter septal occlusion devices are implantable devices delivered via catheter-based access (typically venous access such as the femoral or jugular vein) to close communications between cardiac chambers or vessels. They provide a less invasive alternative to open surgical repair for defects such as secundum atrial septal defects, patent ductus arteriosus, fenestrations after Fontan procedures, and, in some contexts, ventricular septal defects, with the clinical aim of preventing consequences of abnormal intracardiac shunting — including volume or pressure overload, cardiac enlargement, pulmonary hypertension, rhythm disturbances, and paradoxical embolic stroke. Devices used for patent foramen ovale closure must be FDA approved and used as labeled.

Definitions

Transcatheter septal occlusion device — definition and key properties of the implantable device

DefinitionAn implantable device used to repair septal wall defects via catheter-based access to close communications between cardiac chambers or vessels.

PurposeClose atrial or ventricular septal defects to prevent adverse consequences such as abnormal ventricular volume or pressure load, mixing of oxygenated and unoxygenated blood, inadequate systemic cardiac output, cardiac enlargement, pulmonary hypertension, rhythm disturbance, and stroke.

Access routeDelivered percutaneously via venous access (internal jugular or femoral vein).

Clinical advantageProvides a less invasive alternative to open-heart surgical repair, useful when surgical risk or defect location limits surgery.

Device requirementDevices referenced in this policy are implantable transcatheter occlusion systems intended for septal defect closure.