Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that cardiac catheterization is the introduction and positioning of a catheter in the heart to assess 
cardiac function and structure, for diagnosis, treatment planning or to assess therapy. This assessment may 
include the measurement of intracardiac and intra- vascular pressures, obtaining blood samples for blood gas or 
other constituent analysis, determination of cardiac output, injection of contrast for angiography, and 
performing endomyocardial biopsy. The conduct and evaluation of these procedures are then documented and 
interpreted by the physician, in a report. 
 
Cardiac catheterization may be utilized in various clinical situations ranging from those requiring only a right 
heart catheterization to those requiring the performance of right and left heart catheterization with simultaneous 
diagnostic procedures including coronary and bypass angiography, angiography of the cardiac chambers, aortic 
and pulmonary angiography, endomyocardial biopsy, and extra-cardiac angiography. The guidelines in this 
policy outline the indications for coverage of each procedure. 
 
Left Heart Catheterization 
Indications and Limitations for Left Heart Catheterization 
This is the introduction of a catheter(s) into the left ventricle (LV). The catheter may be inserted retrograde 
from the brachial, axillary or femoral artery; by cutdown or percutaneously; or transseptally via a patent 
foramen ovale or by septal puncture; or transapically. The catheterization also includes catheterization of the 
left atrium and aorta when performed with the LV catheterization. It includes all hemodynamic measurements 
(with and without maneuvers and/or infusions or medication), blood sampling and shunt determinations as part 
of the procedure. Placement of multiple catheters and their repositioning or replacement is included in this 
procedure. Injection procedures for selective opacification of cardiac chambers or structures, arteries and 
conduits and the supervision and interpretation of such services are reimbursable as part of all-inclusive codes 
for these services (see Supplementary Instructions Article). 
 
There is no additional reimbursement for a left heart catheterization done for reasons other than hemodynamic 
evaluation or LV angiography required for patient management (i.e., when routinely performed with 
coronary/bypass angiography, electrophysiologic or pacing studies, or endomyocardial biopsies). 
 Left heart catheterization is indicated for the diagnosis of, or treatment planning in patients with myocardial 
abnormalities or dysfunction (including ischemic disease, myocarditis, cardiomyopathy, etc), valvular 
dysfunction, intracardiac shunts, congenital heart abnormalities, cardiac trauma, or pericardial tamponade. 
 
Left Heart Catheterization by Transseptal Puncture 
A catheter with an enclosed transseptal puncture needle is positioned into the right atrium, and under 
fluoroscopic and/or ultrasonic guidance is advanced, puncturing an intact intra-atrial septum thereby entering 
the left atrium. The needle is then removed, leaving the catheter through which a guide wire may be advanced 
to facilitate placement of appropriate catheters into the left atrium and left ventricle. This procedure should not 
be billed if the catheter is advanced into the left atrium through a patent foramen ovale or atrial septal defect. 
 
The transseptal catheterization may be indicated in those cases in which access to the left ventricle is required 
for hemodynamic measurements or angiography, when retrograde access is not feasible or appropriate; when 
access to the left atrium and pulmonary veins is necessary for hemodynamic measurements and angiography; 
and when access to the left atrium and ventricle is necessary for the performance of diagnostic and therapeutic 
electrophysiological procedures. 
 
Cardiac Angiography 
Indications and Limitations for Angiography 
Angiograms of the individual cardiac chambers (atria and ventricles) are indicated for the assessment of mitral 
or tricuspid valve function, ventricular function or morphology (including tumors and clots), suspected 
ventricular aneurysms, intracardiac shunts, congenital heart disease and cardiac trauma. Each procedure (atrial 
or ventricular angiography) may be reimbursed only once regardless of the number of injections of contrast, 
views or actual pictures taken. 
 
Aortography is reimbursable only for diagnoses of aortic root and ascending aorta disease, valvular heart 
disease or congenital heart disease. It is not reimbursable for atherosclerotic heart disease. Angiograms to 
visualize the coronary ostia are included as part of coronary angiography. A diagnosis of rule out (valvular 
lesion) is not reimbursable. 
 
The injection procedure for supravalvular angiography for evaluation of an ascending aortic aneurysm, 
performed during cardiac catheterization, may be covered if it is medically necessary based on the presence of 
signs/symptoms related to an ascending aneurysm or other imaging tests, when providing additional diagnostic 
information. It is not separately payable when performed with a thoracic aortogram. 
 
Coronary angiography is a single procedure which includes arteriograms of all coronary arteries and their 
branches, regardless of the number of vessels selectively catheterized or visualized, with and without the 
administration of diagnostic or therapeutic vasoactive medications. Replacement and repositioning of catheters 
are considered as part of the procedure and are not reimbursable separately. The selective injection procedures 
may be performed without a formal left heart catheterization. Arterial conduit and venous bypass graft 
angiography are reimbursed using the same criteria as are used for the native coronary circulation (reimbursed 
only once regardless of the number of contrast injections, views or films, or whether medications were 
administered). 
 
Coronary and bypass angiography are indicated for the diagnosis of, or treatment planning for patients with 
anginal syndromes, atypical chest pain syndrome suggesting ischemia, congenital heart disease, following 
cardiac arrest suspected to be due to ischemia or infarction, myocardial infarction, known atherosclerotic or 
other coronary disease, suspected graft or stent/PTCA closure, Prinzmetals angina, coronary shunts and 
fistulae, cardiac trauma and for treatment planning in patients undergoing non-coronary cardiac surgical 
procedures (e.g., aortic or mitral valve surgery when not requiring left heart catheterization). It is also indicated 
for treatment planning in high-risk patients with evidence of ischemic heart disease undergoing high-risk non-
cardiac surgical procedures (arterial or aortic surgery, or surgery with large fluid shifts). You can find these rules in the Local Coverage Determination (LCD) Cardiac Catheterization and Coronary 
Angiography L33557. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.