This document addresses alcohol septal ablation (ASA), a less invasive alternative to open surgical septal resection, for the treatment of hypertrophic cardiomyopathy (HCM) in adults. HCM is also referred to as hypertrophic obstructive cardiomyopathy (HOCM).

Clinical Indications

Medically Necessary:

Alcohol septal ablation is considered medically necessary as a treatment of hypertrophic cardiomyopathy (HCM) in individuals age 21 and older when all of the following criteria are met:

1. Severe heart failure symptoms (New York Heart Association [NYHA] class III or IV) or other exertional symptoms (such as syncope or near syncope) refractory to drug therapy; and
2. Left ventricular outflow tract (LVOT) gradient greater than or equal to 50 mm Hg at rest or with physiological provocation, including but not limited to: exercise, Valsalva maneuver or amyl nitrate.

Not Medically Necessary:

Alcohol septal ablation is considered not medically necessary when all of the above criteria are not met.