33141
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.48
Facility
$119.58
Non-Facility
$119.58
Documentation Required
- Documentation that anginal symptoms are caused by viable ischemic myocardium as demonstrated by diagnostic study.
- Documentation that the ischemic myocardium is not amenable to surgical or percutaneous revascularization therapies (PTCA, stenting, coronary atherectomy or coronary bypass).
- Documentation that the option to use an invasive revascularization procedure has been excluded on the basis of a recent coronary angiogram.
- Documentation of maximal efforts to stabilize acute conditions such as severe ventricular arrhythmia, decompensated congestive heart failure or acute myocardial infarction prior to consideration of TMLR.
Key Coverage Criteria
- Aetna considers open chest, and thoracoscopic approaches to transmyocardial laser revascularization (TMLR) medically necessary for the treatment of medically refractory, severe intractable angina (see Appendix for selection criteria).
- CPT codes covered if selection criteria are met: 33140 - 33141 Transmyocardial laser revascularization, by thoracotomy.
- ICD-10 codes covered if selection criteria are met: I20.1 - I20.9 Angina pectoris.
- Anginal symptoms are caused by viable ischemic myocardium (as demonstrated by diagnostic study) not amenable to surgical revascularization therapies such as PTCA, stenting, coronary atherectomy or coronary bypass.
- Member has had maximal efforts to stabilize acute conditions such as severe ventricular arrhythmia, decompensated congestive heart failure or acute myocardial infarction.
- Severe New York Heart Association functional classification of angina pectoris – Class III or IV.
2 Active Policies
AETNA-CPB-0163 — Transmyocardial and Endovascular Laser Revascularization
ANTHEM-SURG.00019 — SURG.00019 Transmyocardial Revascularization
Related Codes
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