Minimally Invasive Coronary Artery Bypass Graft Surgery Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|07|2010 POLICY LAST UPDATED: 2|04|2026 OVERVIEW This medical policy documents the coverage determination for minimally invasive coronary artery bypass graft surgery. There are currently variations on techniques that are classified as “minimally invasive” coronary artery bypass graft (CABG) surgery. The surgery can be done under direct vision, with a mini-sternotomy or a mini-thoracotomy approach. The surgery can also be performed endoscopically, whereby the internal structures are visualized on video monitor, and the entire procedure is performed without direct visualization of the operative field. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Minimally invasive direct coronary artery bypass graft surgery (MIDCAB) may be considered medically necessary. Other techniques for minimally invasive coronary artery bypass graft surgery, including but not limited to port access coronary artery bypass (PACAB), hybrid coronary artery bypass graft (hybrid CABG), or total endoscopic coronary artery bypass (TECAB) techniques, are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial products, as there is insufficient evidence to determine whether outcomes have improved compared to conventional procedures. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for limitations of benefits/coverage when services are not medically necessary. BACKGROUND There are currently variations on techniques that are classified as minimally invasive coronary artery bypass graft surgery. The surgery can be done under direct vision, with a mini-sternotomy or a mini-thoracotomy approach. These types of direct procedures have been termed minimally invasive direct coronary artery bypass. MIDCAB is performed without cardiopulmonary bypass by slowing the heart rate to 40 beats per minute to minimize motion in the surgical field. The performance of a coronary bypass on a beating heart increases the technical difficulty of the procedure, particularly in terms of the quality of the vessel anastomosis. In MIDCAB, the predominant re-anastomosis performed uses the native internal mammary artery to bypass the left anterior descending (LAD) coronary artery. Bypass of the right coronary artery may also be possible in patients with suitable anatomy. The surgery can also be performed endoscopically, whereby the internal structures are visualized on a video monitor, and the entire procedure is performed without direct visualization of the operative field. Cardiopulmonary bypass may or may not be used with this technique. This variation of minimally invasive CABG is called port access coronary artery bypass or total endoscopic coronary artery bypass. Using this approach, theoretically all sides of the heart can be approached. In many instances, only a single bypass of the LAD artery is performed, although multivessel bypass of the left and right coronary artery has been Medical Coverage Policy | Minimally Invasive Coronary Artery Bypass Graft Surgery

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

performed.

Minimally invasive CABG is a surgical procedure and, as such, is not subject to regulation by the U.S. Food & Drug Administration (FDA). The procedure can be performed with conventional instruments or instruments specifically designed for this purpose. Special instruments designed for these procedures are subject to FDA marketing clearance and several manufacturers have received 510(k) clearance to market devices intended for use in minimally invasive CABG. One such device for computer-assisted surgery or robotic technology is the da Vinci® system (Intuitive Surgical, Inc., Mountain View, CA). The da Vinci system received 510(k) marketing clearance from the FDA in 2004 for assisting in coronary artery bypass surgery.

Evidence is insufficient to determine whether PACAB, TECAB, and/or hybrid CABG improve outcomes compared to conventional procedures. Additional randomized comparative studies are needed that compare the relevant short and long-term outcomes from these new techniques with outcomes obtained using the current approaches.

CODING Medicare Advantage Plans and Commercial Products The following HCPCS codes are covered for minimally invasive direct coronary artery bypass graft surgery (MIDCAB): S2205 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or

         mini- sternotomy surgery, performed under direct vision; using arterial graft(s), single 
         coronary arterial graft

S2206 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or

         mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two coronary  
         arterial grafts

S2207 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or

         mini-sternotomy surgery, performed under direct vision; using venous graft only, single 
         coronary venous graft

S2208 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or

         mini-sternotomy surgery, performed under direct vision; using single arterial and venous 
         graft(s), single venous graft

S2209 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or

         mini-sternotomy surgery, performed under direct vision; using two arterial grafts and single  
         venous graft

There are no specific CPT codes for other techniques for minimally invasive coronary artery bypass graft surgery. Therefore, use the code for the unlisted procedure, CPT code 33999.

RELATED POLICIES Unlisted Procedures

PUBLISHED Provider Update, April 2026 Provider Update, March 2025 Provider Update, April 2024 Provider Update, April 2023 Provider Update, June 2022

REFERENCES

1. Diegeler A, Thiele H, Falk V et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med 2002; 347(8): 561-6.
2. Thiele H, Oettel S, Jacobs S et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending artery; a five-year follow-up. Circulation 2005; 112(22):3445-50.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

3. Drenth DJ, Winter JB, Veeger NJ et al. Minimally invasive coronary artery bypass grafting versus percutaneous transluminal coronary angioplasty with stenting in isolated high-grade stenosis of the proximal left anterior descending artery: six months’ angiographic and clinical follow-up of a prospective randomized study. J Thorac Cardiovasc Surg 2002; 124(1):130-5.
4. Reeves BC, Angelini GD, Bryan AJ et al. A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery. Health Technol Assess 2004; 8(16):1-43.
5. Kim JW, Lim DS, Sun K et al. Stenting or MIDCAB using ministernotomy for revascularization of proximal left anterior descending artery? Int J Cardiol 2005; 99(3):437-41.
6. Hong SJ, Lim D-S, Seo HS et al. Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis. Catheter Cardiovasc Interv 2005; 64(1):75-81.
7. Cisowski M, Drzewiecki J, Drzewiecka-Gerber A et al. Primary stenting versus MIDCAB: preliminary report - comparison of two methods of revascularization in single left anterior descending coronary artery stenosis. Ann Thorac Surg 2002; 74(4):S1334-9.
8. Aziz O, Rao C, Panesar SS et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularization for isolated lesions of the left anterior descending artery. BMJ 2007; 334(7594):617-24
9. Bainbridge D, Cheng D, Martin J et al. Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials. J Thorac Cardiovasc Surg 2007; 133(3):623-31.
10. Jaffery Z, Kowalski M, Weaver WD et al. A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery. Eur J Cardiothorac Surg, 2007; 31(4):691-7. 11.Thiele H, Neumann-Schniedewind P, Jacobs S et al. Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis. J Am Coll Cardiol 2009; 53(25):2324-31
11. Kofidis T, Emmert MY, Paeschke HG et al. Long-term follow-up after minimal invasive direct coronary artery bypass grafting procedure: a multi-factorial retrospective analysis at 1000 patient-years. Interact Cardiovasc Thorac Surg 2009; 9(6):990-4.
12. Kettering K. Minimally invasive direct coronary artery bypass grafting” a meta-analysis. J Cardiovasc Surg (Torino) 2008; 49(6):793-800.
13. Dogan S, Graubitz K, Aybek T et al. How safe is the port access technique in minimally invasive coronary artery bypass grafting? Ann Thorac Surg 2002; 74(5):1537-43.
14. Mishra YK, Wasir H, Sharma KK. Totally endoscopic coronary artery bypass surgery. Asian Cardiovasc Thorac Ann 2006; 14(6):447-51.
15. de Canniere D, Wimmer-Greinecker G, Cichon R et al. Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience. J Thorac Cardiovasc Surg 2007; 134(3):710-6.
16. Argenziano M, Katz M, Bonatti J et al. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting. Ann Thorac Surg 2006; 81(5):1666-75.
17. Kappert U, Tugtekin SM, Cichon R et al. Robotic totally endoscopic coronary artery bypass: a word of caution implicated by a five-year follow-up. J Thorac Cardiovasc Surg 2008; 135(4):857-62.
18. Shroyer AL, Grover FL, Hattler B et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 2009; 361(19):1827-37.
19. Puskas JD, Mack JM, Smith CR. Letter to the editor. On-pump versus off-pump CABG. N Engl J Med 2010; 362(9):851.
20. Bonatti J, Schachner T, Bonaros N et al. Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study. Cardiology 2008; 110(2):92-5.

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS