33542
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
47.00
Facility
$2455.63
Non-Facility
$2455.63
Documentation Required
- No specific documentation requirements, prior authorization criteria, or required medical records/test results are stated in this Clinical Policy Bulletin.
- Clinical documentation that the procedure is being performed concomitantly with CABG.
- Documentation of severe, unresponsive CHF and an ejection fraction ≤ 30% when relying on the stated exception to perform ventricular aneurysmectomy with or without SVR/PLV.
- Review the member's benefit contract or Summary Plan Description (SPD) to determine coverage, exclusions, and limitations.
Key Coverage Criteria
- Ventricular aneurysmectomy (ventricular aneurysm repair) performed with or without SVR or PLV when done concomitantly with coronary artery bypass graft (CABG) for severe, unresponsive congestive heart failure (CHF) with ejection fraction (EF) ≤ 30%.
- Surgical ventricular restoration (SVR) to restore or remodel the left ventricle to a more normal spherical shape and size in patients with akinetic left ventricular segments secondary to ischemic dilated cardiomyopathy.
- Partial left ventriculectomy (PLV) as a cardiac restoration/remodeling procedure (included in the scope of procedures such as SVR).
- Surgical ventricular restoration (SVR) performed, usually after CABG, to isolate akinetic or dyskinetic scar tissue and restore more normal left ventricular contour.
- SVR may be performed before or after mitral valve repair/replacement and may be combined with procedures such as endocardectomy and cryoablation for treatment of ventricular tachycardia (VT).
- When the ventricular defect/opening is greater than 3 cm, the ventricle may be reconstructed using patches of autologous or artificial material.
2 Active Policies
AETNA-CPB-0182 — Ventricular Remodeling Operation (Batista Procedure) and Surgical Ventricular Restoration (Dor Procedure)
SUR707.026 — Cardiac Restoration and Remodeling Procedures
Related Codes
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