00133
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Alcohol septal ablation is consideredmedically necessaryas a treatment of hypertrophic cardiomyopathy (HCM) in individuals age 21 and older whenallof the following criteria are met:
- Severe heart failure symptoms (New York Heart Association [NYHA] class III or IV) or other exertional symptoms (such as syncope or near syncope) refractory to drug therapy;and
- Left ventricular outflow tract (LVOT) gradient greater than or equal to 50 mm Hg at rest or with physiological provocation, including but not limited to: exercise, Valsalva maneuver or amyl nitrate.
2 Active Policies
ANTHEM-CG-SURG-102 — CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
ANTHEM-MED.00133 — MED.00133 Ingestion Event Monitors
Related Codes
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