TRANSCATHETER CLOSURE OF SEPTAL DEFECTS
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This policy governs percutaneous transcatheter closure of congenital septal defects (atrial, select non-atrial) and related coding and coverage rules for Priority Health members; coverage depends on member benefits and medical necessity criteria.
Percutaneous transcatheter closure of congenital atrial septal defect is considered medically necessary when InterQual® criteria have been met.
Clarified exclusions to transcatheter closure of septal defects.
Coverage and Medical Necessity Criteria
Medical necessity - Covered indications
Covered when InterQual® criteria are met for percutaneous ASD repair and when indications for select non-atrial defects are present.
Uses InterQual Procedures criteria; provider must document that InterQual criteria have been met
Device must be FDA approved for indication; documentation should support indication and device approval
Medically necessary — Percutaneous transcatheter closure of congenital atrial septal defect
Covered when InterQual® criteria are met.
Documentation should demonstrate that InterQual® criteria have been met; failure to meet InterQual criteria will render the procedure not medically necessary and may result in denial.
Transcatheter closure of septal defects is considered not medically necessary for indications other than those specifically listed as covered. The policy lists multiple exclusion conditions under which transcatheter closure is not appropriate, including but not limited to: severe pulmonary artery hypertension; right-to-left shunt; ostium primum, sinus venosus, or coronary sinus ASD; extensive congenital cardiac anomalies that require open cardiac surgery; inability to take antiplatelet or anticoagulant medications; presence of intracardiac thrombi on echocardiography; patient vasculature too small for the delivery system; any condition that contraindicates cardiac catheterization (for example, infection or sepsis); and defect location that would cause device interference with intracardiac or intravascular structures. The policy also expressly lists exclusions such as procedures performed for migraine prophylaxis, transmyocardial (perventricular) transcatheter closure of ventricular septal defects, and obstructive sleep apnea.
Percutaneous transcatheter closure of congenital atrial septal defect is considered medically necessary only when the proprietary InterQual® criteria for ASD repair have been met; when InterQual® criteria are not met the procedure is considered not medically necessary and subject to denial. The policy change explicitly ties medical necessity for percutaneous ASD closure to meeting these InterQual® criteria.
Exclusions to transcatheter closure of septal defects were clarified in the current revision. The policy emphasizes that detailed exclusion language appears in the policy body and confirms that the following remain exclusionary: severe pulmonary artery hypertension; right-to-left shunt; certain anatomic defect types (including ostium primum, sinus venosus, and coronary sinus ASD); extensive congenital cardiac anomalies only repairable by open surgery; inability to take required antiplatelet/anticoagulant therapy; intracardiac thrombi; insufficient patient vasculature for delivery systems; any contraindication to cardiac catheterization (e.g., infection, sepsis); and defect locations that would interfere with adjacent intracardiac or intravascular structures. The revision note indicates these exclusions were clarified in this update.
Percutaneous transcatheter closure of congenital atrial septal defect is considered NOT medically necessary when the relevant InterQual® criteria have NOT been met. Providers should ensure that documentation submitted for review demonstrates that the InterQual® Procedures subset for Atrial Septal Defect (ASD) Repair — Percutaneous is satisfied. If InterQual® criteria are not met, the service is noncovered and is at risk for denial under this policy.
The policy lists CPT 93581 (Percutaneous transcatheter closure of a congenital ventricular septal defect with implant) and unlisted code 93799 (Unlisted cardiovascular service or procedure for transcatheter ventricular septal defect procedures) as Not Covered. Claims submitted with these codes for transcatheter ventricular septal defect procedures will not be covered under this policy and, where 93799 is used, explanatory documentation accompanying the claim does not make the procedure covered.
Documentation and prior authorization expectations: when prior authorization is required for devices, services, or procedures (for example, covered CPT/HCPCS such as 93580, 93582, or device codes like C1817 and C2628), providers must submit requests that demonstrate medical necessity per Priority Health procedures. Claims should include supporting ICD-10 diagnosis codes that may support medical necessity (for example, Q21.10–Q21.19 for ASD, Q25.0 for PDA, and related codes) and the applicable procedure and device codes. Specifically, documentation should demonstrate that the InterQual® criteria have been met for percutaneous transcatheter closure of congenital atrial septal defect; failure to provide InterQual®-based documentation when required creates a denial risk because the procedure is considered not medically necessary if InterQual® criteria are not satisfied.
Not medically necessary when InterQual® criteria are not met
Percutaneous transcatheter closure of congenital atrial septal defect is considered NOT medically necessary when the InterQual® criteria have not been met. Providers must confirm InterQual® criteria are satisfied before proceeding to avoid a determination of non‑medical necessity.
Billing and Coding
| 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, Prior Authorization, and Documentation
Prior authorization may be required
Prior authorization may be required for certain devices, services, and procedures; when required, providers must submit a request demonstrating that the service is medically necessary per Priority Health procedures (see Provider Manual).
- Follow Priority Health Provider Manual submission instructions when PA is required.
- Requests for individual consideration require prior plan approval and review by a Priority Health medical director or clinical pharmacist.
InterQual® criteria required for coverage
Percutaneous transcatheter closure of congenital atrial septal defect is covered only when the InterQual® criteria for ASD repair have been met; coverage is contingent on meeting those InterQual® procedures criteria.
- Requested service referenced: Atrial Septal Defect (ASD) Repair, Percutaneous (InterQual: CP:Procedures Subset: Atrial Septal Defect Repair).
Provide clear clinical indication and findings
Ensure any prior authorization or case review request clearly documents the indication and relevant clinical findings supporting medical necessity.
Request prior approval for individual case review
If requesting individual case review for investigational or promising treatments, obtain prior plan approval and include supporting rationale for exception.
- Individual consideration requires prior plan approval.
- All determinations for experimental, investigational, or unproven treatments are made by a Priority Health medical director or clinical pharmacist.
Include supporting ICD-10 and procedure/device codes
Claims should include supporting ICD-10 diagnosis codes that may support medical necessity and the applicable CPT/HCPCS procedure and device codes.
Document that InterQual® criteria are met
Documentation submitted for authorization or claims should demonstrate that the InterQual® criteria have been met for percutaneous transcatheter closure of congenital atrial septal defect.
- Reference the specific InterQual® Procedures ASD Repair criteria used to justify medical necessity.
Denial risk if InterQual® criteria not met
Failure to meet the InterQual® criteria for percutaneous transcatheter closure of congenital atrial septal defect would risk denial of coverage.
Background and Clinical Context
An atrial septal defect (ASD) produces a left‑to‑right shunt that increases pulmonary blood flow and can lead to ventricular volume or pressure overload, progressive pulmonary hypertension, arrhythmia, and risk of stroke. Transcatheter septal occluders are permanently implanted devices delivered percutaneously as a less invasive alternative to open surgical repair; these devices are FDA‑classified as Class III under applicable product codes. Preprocedural assessment must identify contraindications such as severe pulmonary artery hypertension (for example, pulmonary arterial systolic pressure or pulmonary vascular resistance approximating greater than two‑thirds systemic), which would generally preclude transcatheter closure.
Definitions and Device Information
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