Anthem Blue Cross Connecticut SURG.00019 Transmyocardial Revascularization Form

This document addresses transmyocardial revascularization.

Position Statement

Medically Necessary:

Open transmyocardial revascularization, also known as transmyocardial laser revascularization, is considered medically necessary for individuals with class III or class IV angina who are not candidates for coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty surgery who meet all of the following criteria:

• Presence of class III or IV angina refractory to medical management; and
• Documentation of reversible ischemia; and
• Left ventricular ejection fraction greater than 30%; and
• No evidence of recent myocardial infarction or unstable angina within the last 21 days; and
• No severe comorbid illness such as chronic obstructive pulmonary disease.

Open transmyocardial revascularization is considered medically necessary as an adjunct to coronary artery bypass graft in those individuals with documented areas of ischemic myocardium that are not amenable to surgical revascularization.

Investigational and Not Medically Necessary:

Percutaneous myocardial revascularization is considered investigational and not medically necessary.

All other uses of transmyocardial revascularization are considered investigational and not medically necessary.