SURG.00019 Transmyocardial Revascularization

This policy addresses transmyocardial revascularization (TMR), including open transmyocardial laser revascularization and percutaneous myocardial revascularization. Open TMR is covered as medically necessary only for patients with refractory Canadian Cardiovascular Society class III–IV angina who are not candidates for CABG or PCI and who also have documented reversible ischemia, left ventricular ejection fraction >30%, and no myocardial infarction or unstable angina within the prior 21 days. Percutaneous TMR and all other uses of TMR (including adjunctive use) are considered investigational and not medically necessary.

"Open transmyocardial revascularization, also known as transmyocardial laser revascularization, is consideredmedically necessaryfor individuals with class III or class IV angina who are not candidat..."

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