CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

This policy addresses alcohol septal ablation (ASA) for treating hypertrophic cardiomyopathy. ASA is medically necessary for individuals age 21 or older who have severe, drug‑refractory symptoms (NYHA class III/IV heart failure or other exertional symptoms such as syncope/near-syncope) and a left ventricular outflow tract gradient ≥50 mm Hg at rest or with physiologic provocation. It is not medically necessary when all of these criteria are not met.

"Alcohol septal ablation is consideredmedically necessaryas a treatment of hypertrophic cardiomyopathy (HCM) in individuals age 21 and older whenallof the following criteria are met:"

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