Anthem Blue Cross Connecticut SURG.00005 Partial Left Ventriculectomy Form

This document addresses partial left ventriculectomy, surgical ventricular remodeling/restoration procedures, and dynamic cardiomyoplasty.

Partial left ventriculectomy (PLV) is a surgical procedure aimed at improving the hemodynamic status of individuals with end-stage congestive heart failure (CHF) by directly reducing left ventricular size. This surgical approach to the treatment of CHF (also known as the Batista procedure or cardio-reduction) is primarily directed at individuals with an underlying dilated cardiomyopathy awaiting cardiac transplantation.

Surgical ventricular remodeling/restoration procedures refer to other techniques designed to restore or remodel the left ventricle to its normal shape or size and may also be referred to as ventricular remodeling, left ventricular reconstruction, endoventricular circular patch plasty, surgical anterior ventricular endocardial restoration (SAVER), or the Dor procedure.

This document also addresses dynamic cardiomyoplasty, a surgical procedure during which skeletal muscle tissue is wrapped around the diseased ventricle. The skeletal muscle is then electrically stimulated to beat in synchrony with the heart and is purported to thereby, improve ventricular functioning.

Position Statement

Investigational and Not Medically Necessary:

Partial left ventriculectomy is considered investigational and not medically necessary in all cases.

Other methods of remodeling or reshaping of the cardiac ventricles to reduce ventricle size with or without surgical removal, (for example, ventricular remodeling or reshaping procedures using ventricular wrapping [dynamic cardiomyoplasty], piercing, or clasping techniques) are considered investigational and not medically necessary in all cases.