Humana Commercial Clinical Policy

Humana Coronary Stents and Angioplasty Form

Effective Date

01/01/2024

Last Reviewed

NA

Original Document

  Reference



Description

A percutaneous coronary intervention (PCI) is used to dilate (widen) narrowed arteries in the heart to relieve chest pain, treat myocardial infarction (heart attack) and potentially enhance activity level. During a PCI, a catheter is advanced to the origin of a coronary artery. A wire with a deflated balloon is then passed beyond the obstruction and advanced into the narrowed part of the coronary artery. Coronary artery angioplasty (also known as percutaneous transluminal coronary angioplasty [PTCA]) is performed when the balloon is inflated to enlarge the channel for blood flow. In most PCIs, a coronary (cardiac) stent (expandable metal mesh tube) crimped on a balloon is then delivered in a similar fashion, and the balloon is inflated to expand the stent, effectively scaffolding the arterial wall to improve blood flow to the heart muscle. As an alternative to angioplasty, atherectomy removes plaque using a rotating shaver or laser at the catheter tip to open narrow or blocked arteries.

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 1 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

To reduce the risk of target vessel restenosis, drug-eluting stents (DES) may be used during PCI. DES vary according to the stent platform, polymer used and antirestenotic drug type (eg, everolimus, ridaforolimus, zotarolimus). Drug-eluting stents are coated with antirestenotic medication that is slowly released after implantation to help prevent build-up of new plaque in the stented artery and prevent restenosis.

Information regarding specific US Food & Drug Administration (FDA)-approved coronary stents may be found on the FDA website.

Intravascular (endoluminal) imaging techniques are used to enhance visualization of coronary vessel or graft lesions during a diagnostic or therapeutic cardiac catheterization procedure in order to guide treatment decisions. Intravascular ultrasound (IVUS) allows visualization of the coronary artery wall by utilizing ultrasound to delineate plaque morphology and distribution and to provide guidance for transcatheter coronary intervention. Optical coherence tomography (OCT) relies on the reflection of light to obtain cross-sectional detailed images of the coronary artery to characterize the structure and extent of atherosclerosis and assess acute stent placement.

Coronary sinus venography uses a contrast media injection to visualize the coronary venous system for such indications as cardiac ablation, cardiac resynchronization therapy, congenital cardiac defect repair and/or pacemaker lead placement.

Coverage Determination

Angioplasty with or without coronary stent implantation deemed urgent/emergent (eg, cardiogenic shock, non-ST segment elevation myocardial infarction [non-STEMI], STEMI, unstable chest pain/angina) are not subject to the criteria within this medical coverage policy.

Humana members may be eligible under the Plan for angioplasty with or without coronary stent implantation for the following indications:

  • Coronary artery disease (CAD) treatment in conjunction with planned percutaneous valve procedure (eg, transcatheter aortic valve replacement); OR
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Coronary artery diameter stenosis greater than 70% (other than left main artery) with 1 or more of the following:
    1. Fractional flow reserve (FFR) less than or equal to 0.80; OR
    2. Instantaneous wave free ratio (iFR) less than or equal to 0.89; OR
    3. Lifestyle-limiting chest pain* despite guideline directed medical therapy (GDMT)**; OR
  • In-stent restenosis as evidenced by the following:
    1. Chest pain* or myocardial ischemia; AND
    2. Individual expected to tolerate postprocedural dual antiplatelet therapy (eg, clopidogrel or ticagrelor and aspirin); AND either of the following:
      1. Greater than or equal to 70% restenosis of a non-left main coronary vessel; OR
      2. Greater than or equal to 50% restenosis of the left main artery; OR
  • Left main coronary artery stenosis appropriate for percutaneous coronary intervention (PCI) as indicated by:
    1. Anatomic conditions associated with low to intermediate risk of PCI procedural complications and intermediate to high likelihood of good long- term outcome (eg, SYNTAX score less than 33); AND
    2. Significant stenosis as indicated by 1 or more of the following:
      1. 50% or greater luminal diameter stenosis; OR
      2. FFR less than or equal to 0.80; OR
      3. iFR less than or equal to 0.89; OR
      4. Lumen area less than 6 square millimeters; OR
      5. Lumen diameter less than 2.8 millimeters
      AND either of the following:
      1. High surgical revascularization risk as determined by a heart team (including a cardiac surgeon and an interventional cardiologist) that is associated with clinical characteristics such as moderate to severe chronic obstructive pulmonary disease (COPD), disability from prior stroke, prior cardiac surgery, and/or Society of Thoracic Surgery [STS] Predictive Risk of Mortality greater than 2% (not an all-inclusive list); OR
      2. Individual chooses not to undergo surgical revascularization as documented in the clinical record
    *Chest pain includes pain, pressure, tightness or discomfort in the chest, shoulders, arms, neck, back, upper abdomen or jaw, as well as shortness of breath and fatigue and should all be considered anginal equivalents.**GDMT represents individualized optimal medical therapy and lifestyle modifications for CAD and may include antianginal, antihypertensive, antiplatelet and statin or other lipid-lowering therapies along with diet modification, physical activity and smoking cessation.

Humana members may be eligible under the Plan for intravascular ultrasound or ocular coherence tomography for intravascular imaging of coronary vessel or graft lesions during a diagnostic or therapeutic cardiac catheterization procedure.

Note: The criteria for coronary stents and angioplasty are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for angioplasty or coronary stents for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about atherosclerosis and coronary artery disease may be found from the following websites:

  • American Heart Association
  • National Heart, Lung and Blood Institute
  • National Library of Medicine

Medical Alternatives

Alternatives to coronary stents and angioplasty include, but may not be limited to, the following:

  • Coronary artery bypass graft (CABG)
  • Prescription drug therapy

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • 92925 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
  • 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
  • 92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
  • 92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch
  • 92934 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
  • 92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel
  • 92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure)
  • 92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel

Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 7 of 13
  • 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel
  • 92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)
  • 92978 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure)
  • 92979 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure)
  • 93586 Venography for congenital heart defect(s), including catheter placement, and radiological supervision and interpretation; coronary sinus New Code Effective 01/01/2024

CPT® Category III Code(s)

  • c9600 intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 8 of 13

Humana's documents are updated regularly online.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

c9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch

C9603 Percutaneous transluminal coronary atherectomy, with drug- eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure)

C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel

C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel

References

  • Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review (ARCHIVED). Intravascular diagnostic procedures and imaging techniques versus angiography alone in coronary artery stenting. https://www.ahrq.gov. Published February 26, 2013. Accessed April 18, 2023.
  • Agency for Healthcare Research and Quality (AHRQ). Technical Brief (ARCHIVED). Vulnerable atherosclerotic plaque. https://www.ahrq.gov. Published August 16, 2010. Accessed April 18, 2023.
  • American College of Cardiology (ACC). 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. https://www.acc.org. Published November 4, 2014. Accessed April 19, 2023.
  • American College of Cardiology (ACC). 2020 ACC/AHA guideline for the management of patients with valvular heart disease. https://www.acc.org. Published February 2, 2021. Accessed April 19, 2023.
  • American College of Cardiology (ACC). 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. https://www.acc.org. Published January 18, 2022. Accessed April 19, 2023.
  • SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. American College of Cardiology (ACC). 2021 AHA/ACC/ASE/CHEST/SAEM/ https://www.acc.org. Published November 30, 2021. Accessed April 19, 2023.
  • American College of Cardiology (ACC). 2022 AHA/ACC/HFSA guideline for the management of heart failure. https://www.acc.org. Published November 30, 2021. Accessed April 19, 2023.
  • American College of Cardiology (ACC). ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes. https://www.acc.org. Published February 7, 2017. Accessed April 19, 2023.
  • American College of Cardiology (ACC). ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 appropriate use criteria for coronary revascularization in patients with ischemic heart disease. https://www.acc.org. Published May 2, 2017. Accessed April 19, 2023.
  • American College of Cardiology (ACC). ACCF/SCAI/AATS/AHA/ASE/ASNC/ HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization. https://www.acc.org. Published May 29, 2012. Accessed April 19, 2023.
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • American Heart Association (AHA). AHA Scientific Statement. Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus. https://www.heart.org. Published May 12, 2020. Accessed April 19, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Percutaneous transluminal angioplasty (PTA) (20.7). https://www.cms.gov. Published January 1, 2013. Accessed April 18, 2023.

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 10 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • ClinicalKey. Kern M. The basics of percutaneous coronary intervention. In: Lim MJ, Sorajja P, Kern M. The Interventional Cardiac Catheterization Handbook. 5th ed. Elsevier; 2023:1-63. https://www.clinicalkey.com. Accessed May 9, 2023.
  • ClinicalKey. Kumbhani DJ, Bhatt DL. Percutaneous coronary intervention. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:786-805. https://www.clinicalkey.com. Accessed April 18, 2023.
  • ClinicalKey. Palmerini T, Kirtane AJ. Coronary Stenting. In: Topol EJ, Tierstein PS. Textbook of Interventional Cardiology. 8th ed. Elsevier; 2020:235-286.e16. https://www.clinicalkey.com. Accessed April 18, 2023.
  • ClinicalKey. Tierstein PS. Interventional and surgical treatment of coronary artery disease. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:401-406.e2. https://www.clinicalkey.com. Accessed April 18, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Intravascular optical coherence tomography for evaluating coronary artery disease. https://www.ecri.org. Published September 11, 2019. Accessed April 17, 2023.
  • ECRI Institute. Hotline Response (ARCHIVED). Intravascular ultrasound for evaluating coronary artery disease. https://www.ecri.org. Published August 8, 2018. Accessed April 17, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief. Optical coherence tomography (OCT) for plaque characterization and stent implantation. https://evidence.hayesinc.com. Published January 11, 2023. Accessed April 17, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of biolimus-eluting stents versus bare-metal stents and second-generation drug-eluting stents. https://evidence.hayesinc.com. Published April 14, 2016. Updated August 6, 2020. Accessed April 17, 2023.

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 11 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness of bioresorbable vascular scaffold stents versus other drug- eluting stents for the treatment of coronary artery disease. https://evidence.hayesinc.com. Published November 7, 2017. Updated January 6, 2022. Accessed April 17, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of everolimus- and zotarolimus- eluting stents for coronary artery disease. https://evidence.hayesinc.com. Published May 19, 2016. Updated September 8, 2020. Accessed April 17, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Intravascular ultrasound (IVUS) for guidance of percutaneous coronary interventions. https://evidence.hayesinc.com. Published July 22, 2010.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Paclitaxel-eluting stents for treatment of coronary artery disease. https://evidence.hayesinc.com. Published December 14, 2010. Updated January 13, 2014. Accessed April 17, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Sirolimus-analog- eluting stents for treatment of coronary artery disease. https://evidence.hayesinc.com. Published December 14, 2010. Updated December 10, 2015. Accessed April 17, 2023.
  • Heart Failure Society of America (HFSA). 2010 comprehensive heart failure practice guideline. Section 13: evaluation and therapy for heart failure in the setting of ischemic heart disease. https://www.hfsa.org. Published 2010. Accessed April 19, 2023.
  • MCG Health. Angioplasty, percutaneous coronary intervention. 26th edition. https://www.mcg.com. Accessed April 5, 2023.
  • Merck Manual: Professional Version. Percutaneous coronary interventions. https://www.merckmanuals.com. Updated September 2022. Accessed April 18, 2023.

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 12 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Bioresorbable scaffold coronary artery stents. https://www.uptodate.com. Updated March 31, 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Clinical use of intracoronary bare metal stents. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Coronary artery stent thrombosis: incidence and risk factors. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Drug-eluting intracoronary stents: stent types. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Heart transplantation: prevention and treatment of cardiac allograft vasculopathy. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Intracoronary stent restenosis. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Intravascular ultrasound, optical coherence tomography and angioscopy of coronary circulation. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Long-term antiplatelet therapy after coronary artery stenting in stable patients. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Nickel hypersensitivity and coronary artery stents. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Percutaneous coronary intervention of specific coronary lesions. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.

Coronary Stents and Angioplasty

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0582-004

Page: 13 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Percutaneous coronary intervention with intracoronary stents: overview. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: periprocedural management. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.
  • UpToDate, Inc. Revascularization in patients with stable coronary artery disease: coronary artery bypass graft surgery versus percutaneous coronary intervention. https://www.uptodate.com.
  • UpToDate, Inc. Specialized revascularization devices in the management of coronary heart disease. https://www.uptodate.com. Updated March 2023. Accessed April 18, 2023.