Intravascular Optical Coherence Tomography (CPB 0829, reviewed 2026-04-27)

By 2026-04-27: Billing team must reprogram claims processing system to implement strict OCT coverage criteria. ACTION ITEMS: (1) For CPT 92978, 92979, C7516, C7518, C7521, C7523, C7525, C7527: Claims are COVERED ONLY if diagnosis is I20.0 or I21.xx (ACS) AND procedure targets LEFT MAIN artery or COMPLEX LESION—require provider documentation of vessel location and lesion complexity in medical records before claim submission. All other coronary indications require denial with notification to provider. (2) For CPT 0984T, 0985T, 0986T, 0987T (cerebral vessel OCT): AUTOMATICALLY DENY all claims as experimental/investigational per policy. Do not submit for prior authorization. (3) For all other OCT indications not meeting ACS left main/complex lesion criteria (carotid stenosis, renal artery follow-up, bifurcation evaluation, pulmonary artery assessment, etc.): DENY as experimental/investigational. (4) Update billing software rules, encounter form templates, and provider alerts. (5) Providers must document in clinical notes: diagnosis code (I20.0 or specific I21.xx), vessel treated (confirm LEFT MAIN or complex lesion designation), and clinical justification. Failure to document will result in claim denial. Notify cardiology and interventional teams of coverage restrictions immediately.