Aetna considers alcohol septal ablation (PTSMA) medically necessary for adults 21 years of age and older with hypertrophic obstructive cardiomyopathy when all listed criteria are met, including a clinical diagnosis of hypertrophic cardiomyopathy by echocardiography or cardiovascular MRI, severe symptoms that interfere with activities of daily living despite optimal drug therapy, NYHA functional class III or IV, and a peak LVOT gradient of 50 mm Hg or more. Aetna also considers PTSMA medically necessary for carefully selected members aged 5 to 20 with HOCM who meet separate pediatric criteria, and considers PTSMA for all other indications, SESAME, and ultrasound-guided PTSMA experimental, investigational, or unproven.
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01Billing team: for CPT 93583 (percutaneous transcatheter septal reduction therapy, eg alcohol septal ablation, including temporary pacemaker insertion when performed), confirm the record supports the adult criteria: a hypertrophic cardiomyopathy diagnosis by echocardiography or cardiovascular MRI with maximal LV wall thickness of 15 mm or more, or 13 to 14 mm with a first-degree family history of HCM or a confirmed pathogenic or likely pathogenic sarcomere gene variant; severe symptoms that interfere with activities of daily living despite optimal drug therapy, dual chamber pacing and/or ineffective previous surgical myotomy/myectomy; NYHA class III or IV; a peak LVOT gradient of 50 mm Hg or more at rest or with physiologic provocation; suitable coronary anatomy with an identifiable septal perforator artery; and no listed contraindication (concomitant cardiac disease requiring surgical correction, a fixed subaortic membrane or supravalvular stenosis as the primary cause of obstruction, or coronary artery disease that would preclude safe performance).
02For members aged 5 to 20, the record needs an age-appropriate diagnosis that includes z-score-based LV wall thickness assessment and documentation that the member is not an appropriate candidate for surgical septal myectomy due to contraindications, high surgical risk, or other clinical considerations.
03Covered ICD-10 codes include I42.1 (obstructive hypertrophic cardiomyopathy); I42.2 (other hypertrophic cardiomyopathy) is listed as not covered.
04SESAME and ultrasound-guided PTSMA have no specific CPT code and are listed as not covered.
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