S0735
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Transcatheter closure of a patent foramen ovale (PFO) using a U.S. Food and Drug Administration (FDA) approved device approved for that indication is consideredmedically necessaryfor:
- The prevention of subsequent stroke in individuals with a history of cryptogenic stroke when either criteria set below are met:60 years old and younger and the following:an atrial septal aneurysm;ora large interatrial shunt (see definition section)Any age and the following:Have failed conventional drug therapy (for example, warfarin);orAre not candidates for conventional drug therapy.
- 60 years old and younger and the following:an atrial septal aneurysm;ora large interatrial shunt (see definition section)
- an atrial septal aneurysm;or
- a large interatrial shunt (see definition section)
- Any age and the following:Have failed conventional drug therapy (for example, warfarin);orAre not candidates for conventional drug therapy.
2 Active Policies
ANTHEM-MED.00134 — MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring Systems
ANTHEM-SURG.00032 — SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Related Codes
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