C1817 — Septal defect implant system, intracardiac
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- For PDA: clinical documentation supporting device selection (policy references use of Amplatzer ductal occluder in moderate-to-large PDAs and prior trials showing use in pediatric population).
- General documentation implied by policy: pre-procedure and follow-up echocardiography (TEE/TTE) and clinical follow-up notes (policy cites necessity of pre-procedure and post-procedure echo and follow-up schedules in clinical studies).
- No explicit documentation requirements (e.g., precise CMS/Medicare medical necessity statement or required ICD-10 documentation) are stated in the provided text.
- Echocardiographic morphology documentation for ASDs: 'echocardiographic morphology of the ASD with reference to size, position in the interatrial septum, proximity to surrounding structures, and adequacy of septal rim.'
Key Coverage Criteria
- 93582 Percutaneous transcatheter closure of patent ductus arteriosus
- Aspiration thrombectomy with the AngioVac system for percutaneous removal of thrombus in the venous system.
- Right-sided transcatheter vacuum-assisted mass extraction (TVME) including: right-sided heart chamber thrombi, right-sided infective endocarditis (RSIE) vegetations, venous thrombus, lead-related infection/thrombus aspiration, and right-sided cardiac mass evacuation.
- AngioVac-assisted vegetation debulking (AVD) for right-sided infective endocarditis (RSIE) — described in systematic reviews and case series with reported procedural and clinical success.
- Percutaneous vacuum-assisted debulking of large vegetations as an adjunct to lead extraction.
- Transcatheter vacuum-assisted left-sided mass extraction (left-sided TVME) — reported in small case series and single-center reports (noted as limited/experimental/off-label use in the text).
2 Active Policies
HUMANA-LEFT-ATRIAL-APPENDAGE-AND-CARDIAC-STRUCTURAL-DEFECT-CLOSURE-MA — Left Atrial Appendage and Cardiac Structural Defect Closure - Medicare Advantage
AETNA-CPB-0292 — Catheter-Directed Cardiac Procedures
Related Codes
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