CommercialCoverageHigh impact
Catheter-Directed Cardiac Procedures (CPB 0292, reviewed 2026-08-04)
Aetna·Cardiology, Cardiothoracic Surgery, Pediatrics +1 more·Medical Policy
Effective date
Aug 4, 2026
We identified it
Aug 14, 2026
Summary
Aetna has updated its Clinical Policy Bulletin 0292 on catheter-directed cardiac procedures (reviewed 2026-08-04), establishing medical necessity criteria for transcatheter closure of atrial septal defects (ASDs), ventricular septal defects (VSDs), patent foramen ovale (PFO), and patent ductus arteriosus (PDA). The policy specifies approved devices, clinical selection criteria, and designates certain procedures and off-label uses as experimental/investigational, which will be non-covered. Billing teams must immediately align claim submissions and prior authorization reviews to these updated criteria.
Action Required
Immediately effective 2026-08-04: (1) Billing team must update prior authorization protocols to require documentation of medical necessity criteria for covered procedures: CPT 93580 (ASD closure) requires Qp:Qs ≥1.5, RV enlargement, and specified PVR thresholds; CPT 93581 (VSD closure) requires high-risk complex VSD designation; CPT 93582 (PDA occlusion) requires FDA-approved device verification. (2) Implement system edits to deny or place on hold all claims for non-covered procedures listed in 'Experimental, Investigational, or Unproven' section, including: CPT 0613T (interatrial septal shunt), PFO closure for migraine (CPT 93580 with ICD-10 G43.001-G43.E19), ASD closure for migraine, and VSD closure for unlisted indications. (3) Reject claims for devices not FDA-approved (Nit-Occlud Lê coil, Neovasc Reducer, AngioVac System) with explanation that they are investigational. (4) Update billing software encounter forms to require provider documentation of stroke type (non-lacunar, cryptogenic) and shunt characteristics (≥20 bubbles or atrial septal aneurysm) for PFO cases (CPT 93580, ICD-10 I63.9). (5) Verify all HCPCS device codes (C1817 for approved occluders; reject claims with unapproved devices). Failure to implement these controls will result in claim denials and potential overpayments requiring recovery.