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Medical Policy

Policy Num:       02.002.001
Policy Name:     Percutaneous Transluminal Coronary Angioplasty
Policy ID:          [02.002.001] [Ar / B / M +/ P- ]   [2.02.03]

Last Review:       August 31, 2023
Next Review:      Policy Archived

ARCHIVED
 

Related Policies: None

Percutaneous Transluminal Coronary Angioplasty

Summary

Primary percutaneous transluminal coronary angioplasty (PTCA), also referred to as direct, immediate, or infarct angioplasty, is one method to intervene with acute myocardial infarction symptoms. It is intended to be performed within 6 to 12 hours of the onset of acute myocardial infarction symptoms. It was developed as an alternative to thrombolytic therapy (thrombolytic drugs administered to dissolve thrombi).

Objective

The objective of this evidence-based review is the evaluation of  Primary percutaneous transluminal coronary angioplasty (PTCA) in the acute setting of coronary symptoms.

Policy Statements

Percutaneous coronary transluminal angioplasty is considered for payment in the treatment of acute myocardial infarction as an alternative method for patients who do not have contraindications for thrombolysis.

Coronary transluminal percutaneous angioplasty is considered for payment as the first option for patients with contraindications for thrombolysis such as cardiogenic shock, advanced age, or a previous history of coronary bypass.

Policy Guidelines

Percutaneous coronary intervention (PCI) may be indicated in the management of:

 Patients with acute coronary syndrome (e.g., acute myocardial infarction, unstable angina)

 Patients with a history of significant obstructive atherosclerotic disease

 Patients with restenosis of a coronary artery previously treated with an intracoronary stent or other revascularization procedure

 Patients with chronic angina

 Patients with silent ischemia

 Patients that can be managed medically

Generally, PCI is not indicated for:

 Right heart catheterization and insertion of a Swan-Ganz catheter are not generally medically necessary for a PCI and will be denied, unless medically necessary when performed incident to a diagnostic catheterization prior to the intervention

 Standby services of a surgeon or anesthesiologist are not covered services

 Patients with stable coronary artery disease (CAD)

Modifier

Claims for percutaneous coronary intervention must include the appropriate modifiers to identify which vessel is undergoing a specific procedure. Modifiers are identified as: LD (left anterior descending coronary artery), LC (left circumflex coronary artery), RC (right coronary artery), LM (left main artery), and RI (rasmus intermedius artery)

Benefit Application

BlueCard/National Account Issues N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Percutaneous coronary intervention (PCI) is a minimally invasive non-surgical procedure performed to improve blood flow in one or more segments of the coronary circulation. Coronary revascularization with PCI primarily involves the use of balloon angioplasty and intracoronary stenting with either drug-eluting stents (DES) or bare-metal stents (BMS); other tools to improve coronary blood flow include atherectomy and radiation.

DES reduces the rate of restenosis and (accordingly) target lesion revascularization compared with BMS, which are no longer commonly used. The majority of DES consists of a metallic alloy stent, a polymer coating (which may be durable or bioabsorbable), and an antirestenotic drug that is mixed within the polymer and is released over a period of weeks to months after implantation to reduce the local proliferative healing response. DES types currently approved in the United States for use in the coronary circulation.

Regulatory Status

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Rationale

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Percutaneous coronary intervention (PCI) refers to both non-stenting procedures and stent interventions. Stenting represented an advance over balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]) alone because acute procedural success was higher and the rate of restenosis requiring target lesion revascularization was much lower. Approximately 20 to 30 percent of patients required clinically driven repeat target lesion revascularization within the first year after PTCA alone compared with 10 to 15 percent with bare-metal stents.

Drug-eluting stents (DES) represented a further advance in PCI and are now used in the majority of procedures. In addition, newer generation DES are used in preference to first-generation DES.

Left main and left anterior descending disease — Left main, left main equivalent, and proximal left anterior descending disease are associated with a relatively large amount of myocardium at risk. The possible indications for efficacy of drug-eluting stents (DES) with these lesions are discussed separately.

Multivessel revascularization 

Potential concerns — There are potential concerns with multivessel and complex lesion treatment with DES that may limit its use compared to coronary artery bypass graft surgery (CABG) [4]:

●A high risk of subacute and late stent thrombosis (5 of 17 [29 percent] in one series) in patients who prematurely discontinue antiplatelet therapy with aspirin and clopidogrel. 

●A more pronounced increase in revascularization rate compared to CABG, especially in diabetic patients (12.6 versus 4.2 percent) 

●A greater likelihood that such patients will have progressive coronary disease in areas not protected by stenting. In a review of 3747 percutaneous coronary interventions (PCIs) from the National Heart, Lung, and Blood Institute Dynamic Registry, 216 (5.8 percent) required nontarget lesion PCI at one year: 87 percent of these nontarget lesions were ≤60 percent stenosis at initial PCI (mean 42 percent compared to 84 percent during the recurrent event) 

●A greater likelihood of incomplete revascularization after PCI compared to CABG, particularly in patients with decreased left ventricular systolic function.

Complete versus incomplete revascularization — The concerns raised in the section above result, at least in part, from attempts to completely revascularize the coronary circulation using PCI in a manner similar to that done with CABG. The concept that complete revascularization (CR) leads to better outcomes than incomplete revascularization (IR) was based on outcomes seen in older CABG studies and predate modern medical therapy.

The hypothesis that CR is superior has been challenged by studies performed in patients on optimal medical therapy and who receive current CABG and PCI techniques, including DES. Early studies comparing IR to CR in patients undergoing stenting found higher rates of death] and the need for repeat revascularization. Most, but not all, of these studies were in patients who received bare-metal stents.

Outcomes after CR and IR were compared in a single-center registry report of 1914 patients undergoing PCI (n = 1400) with DES or CABG (n = 514) for multivessel CAD. CR was achieved in 41 and 67 percent of those receiving PCI or CABG, respectively. Using a definition of CR (applied to the diagnostic angiogram) as any attempt to revascularize all disease segments ≥1.5 mm, no significant difference was found between those with CR and those with IR in the adjusted rates of five-year death (8.9 versus 8.9 percent; adjusted hazard ratio 1.04, 95% CI 0.76-1.43 respectively) or the composite of death, MI, or stroke (12.1 versus 11.9; adjusted hazard ratio 1.04 95% CI 0.79-1.36). The results were similar for analyses performed on only those patients who underwent PCI.

Based on the available evidence, we suggest that for patients with multivessel disease undergoing PCI due to angina refractory to medical therapy, an attempt should be made to revascularize all lesions likely to impair coronary flow to moderate or large areas of viable myocardium. The results of noninvasive imaging techniques performed before PCI or the determination of fractional flow reserve during the procedure may be useful in this regard. 

Overlapping stents — A potential concern with longer lesion treatment is that overlapping DES may result in adverse effects due to possible drug toxicity or polymer instability in the overlap segment. However, the use of multiple overlapping DES for very long lesions was relatively safe and associated with good intermediate-term outcomes in two small series.

In one of these reports, 66 patients with diffuse disease of the left anterior descending artery (average lesion length about 80 mm) were treated with multiple (mean 2.8) sirolimus or paclitaxel stents [23]. The following findings were noted:

●Angiographic and procedural success was achieved in 95 percent of patients

●Eleven patients (17 percent) developed a non-ST elevation MI in hospital, and one patient developed stent thrombosis.

●At follow-up angiography at six months in 52 patients, 10 (19.6 percent) had restenosis; most of the lesions were focal.

●At an average follow-up of 13.6 months, there were no deaths, one patient had a non-ST elevation MI, 10 (15 percent) required target vessel revascularization, and one patient required CABG.

Overlapping stents are associated with greater late lumen loss and more frequent angiographic restenosis than single stents. However, a subset analysis from three randomized trials and two prospective observational studies comparing sirolimus to bare-metal stents found that the magnitude of the restenosis benefit of sirolimus stents was similar in overlapping and single stents.

Concerns have been raised about possible persistent inflammation and delayed reendothelialization at overlapping compared to nonoverlapping sites. A pathologic study in a rabbit iliac artery model of overlapping sirolimus and paclitaxel stents found evidence for increased inflammation and delayed healing for drug-eluting compared with bare-metal stents. These changes were more pronounced at overlapping than nonoverlapping sites.

Very long lesions — The efficacy of DES for very long lesions (median 79 mm, range 64 to 168 mm) was evaluated in a series of 122 patients with de novo lesions; multiple overlapping stents were used (mean 3.3 per lesion), an approach that has been called "full metal jacket". Periprocedural MI occurred in two patients (1.6 percent). At one year, the overall rate of major adverse cardiac events was 18 percent, including target vessel revascularization in only 7.5 percent, nonfatal MI in 8.2 percent, and death in 4.1 percent. There was only one case of subacute stent thrombosis and the outcomes were similar with sirolimus and paclitaxel stents.

Bifurcation lesions — Bifurcation lesions can be defined as stenoses involving the origin of an arterial side branch that is ≥2.0 mm in diameter. It has been estimated that bifurcation lesions are present in 15 to 20 percent of lesions treated at the time of PCI. These lesions are more difficult to treat due in part to differences in anatomic patterns of stenosis, variations in the diameter of each of the branches, and the angle at which the side branch comes off the main branch. Some lesions are particularly challenging and have been called complex coronary bifurcation lesions.

The degree of ostial side branch stenosis is the primary determinant of the need for side branch protection. Treatment of bifurcation lesions with stenting has been associated with an increase in early complications, including compromise of the branch vessel or the target lesion, with the potential for myocardial infarction, and enhanced potential for restenosis involving either the parent vessel or side branch. In addition, stenting may impair access to the side branch.

PCI with DES is performed in most patients [. In selected patients, a debulking procedure such as directional or rotational atherectomy is combined with DES. 

Main versus main plus side branch stenting — In most cases, we suggest a strategy of main vessel only stenting with provisional stenting of the side branch ("provisional" approach) rather than a strategy of main plus side branch stenting, which has been referred to as "dedicated" or "complex" side branch stenting. However, for patients with complex bifurcation lesions, a two-stent technique is a reasonable approach.

At least four randomized trials, each using somewhat different techniques, have compared these two approaches:

●In the TRYTON trial, 704 patients with bifurcation lesions were randomly assigned to a main vessel stent plus provisional stenting or a dedicated bifurcation stent. The bifurcation stent, the Tryton Side Branch Stent, is a non-drug-eluting stent that requires implantation of a DES in the main branch to lock the device in place. At nine months, the rate of primary endpoint of target vessel failure (cardiac death, target vessel MI, and target vessel revascularization) was lower with provisional main vessel stenting (12.8 and 17.4 percent, respectively). The difference of 5.6 percent exceeded the pre-specified non-inferiority margin for the bifurcation stent of 5.5 percent; the difference was primarily attributable to an increase in the rate of MI (10.1 versus 13.6 percent). In a subsequent single-arm registry and post-hoc analysis that was restricted to side branches >2.25 mm in diameter, the Tryton device met a pre-specified performance goal and has received United States Federal Drug Administration approval for use in these larger side branches.

●In the Nordic Bifurcation trial of 413 patients, there was no significant difference in the rate of major adverse cardiac events (MACE), defined as death, non-procedure-related MI, target vessel revascularization, or stent thrombosis, between the two-stent and provisional groups (3.4 versus 2.9 percent, respectively) at six months. At five-year follow-up, freedom from MACE was not significantly different in the two groups (78.2 versus 84.2 percent, respectively).

●In the CACTUS trial of 350 patients, there was no significant difference in the rate of MACE (death, MI, and target vessel revascularization) between a two-stent technique with "crush stenting" and provisional groups (15.8 versus 15 percent respectively) at six months.

●In the BBC ONE trial of 500 patients, the primary endpoint (a composite of death, MI, and target-vessel failure) occurred significantly more often in the multistent group (15.2 versus 8.0 percent; hazard ratio 2.20, 95% CI 1.17-3.47), attributable principally to a significantly higher rate of MI (11.2 versus 3.6 percent) at nine months.

In these trials, patients assigned to complex procedures had statistically longer procedure and fluoroscopy times, higher contrast volumes, and higher rates of procedure-related increases in biomarkers of myocardial injury. The rate of side branch stenting in the provisional group of these studies varied from 4 to 30 percent.

Based upon the available evidence, including the fact that most side branches have a normal fractional flow reserve and presumed good outcome irrespective of angiographic severity [39], we recommend a strategy of limiting stent implantation to the main vessel using a DES for patients with bifurcation lesions. Side branch stent placement is appropriate for significant dissection, reduced flow, or clinical evidence of ischemia.

Patients who may benefit from a dedicated two-stent approach include those with complex bifurcation lesions.

The DEFINITION II trial randomly assigned 653 patients with complex bifurcation lesions to a two-stent technique or provisional stenting. For the two-stent techniques, the DK crush (78 percent) or culotte stenting methods were strongly recommended. In DEFINITION II, 29 percent of lesions were in the distal left main coronary artery. The primary endpoint (a composite of target lesion failure at one-year follow-up, including cardiac death, target vessel MI, and clinically driven target lesion revascularization) occurred in 11.4 and 6.1 percent of the two groups, respectively (hazard ratio 0.53, 95% CI 0.30-0.90). There was a nonsignificant higher rate of cardiac death in the provisional group (2.5 versus 2.1 percent). The findings in DEFINITION II are consistent with other studies.

Final kissing balloon dilation — Although final kissing balloon inflation is always required with two-stent strategies, the issue of whether simultaneous balloon dilatation of both the main vessel and the side branch (final kissing balloon dilatation [FKBD]) is necessary after placement of a stent in only the main vessel was addressed in the Nordic-Baltic Bifurcation Study III [44]. In this trial, 477 patients with either stable or unstable disease and a bifurcation lesion were randomly assigned to either FKBD or no FKBD after stenting of the main vessel. Stenting of the side branch was allowed if, after FKBD, side branch TIMI flow grade was less than 3 (ie, less than normal flow which fills the distal bed completely).

At six months, there was no significant difference in the rate of the primary composite endpoint (cardiac death, non-procedure-related index lesion MI, target lesion revascularization, or definite stent thrombosis) between the FKBD and no FKBD groups (2.1 and 2.5 percent, respectively). As expected, based upon the experience comparing main versus main plus side branch stenting discussed in the preceding section, FKBD resulted in increased use of contrast media and longer procedure and fluoroscopy times. This is in contrast to dedicated two stent strategies, wherein FKBD is almost always advised.

We suggest FKBD in all two-stent approaches, but we suggest single-stent bifurcation treatment only in cases where there is reduced flow or other evidence of ischemic compromise involving a side branch that supplies at least a moderate myocardial territory.

Side branch stenting techniques — When the side branch is stented, many techniques have been utilized and are discussed in detail elsewhere.

Summarized briefly:

●The simplest is provisional side branch stenting, in which a single stent is placed in the main vessel, and balloon dilation or stenting of the side branch is performed only if branch compromise ensues.

●Pre-emptive stenting of both the main vessel and side branch, either by simultaneous inflation of the two stents side by side over a short distance proximal to the bifurcation (simultaneous kissing stents), "culotte" technique, in which a second stent is deployed through a strut of an initially placed stent in the parent vessel of side branch, overlapping the first stent for a short distance, or a variety of so-called "T" or "Y" techniques.

●In the crush technique, the proximal end of the stent in the side branch is crushed against the vessel wall as the second stent is deployed in the parent vessel in an attempt to optimize stent coverage of the entire plaque surface at the carina. A final kissing balloon postdilation is essential and is performed by re-advancing a guidewire and angioplasty balloon through the sides of the parent vessel stent into the side branch and inflating simultaneously with a second balloon positioned within the parent stent. Most investigators have abandoned the basic technique due to lack of demonstrated benefit, possible increased safety concerns, and uncertainty of achieving final kissing balloon inflation in all cases. A modification of the technique has been developed using a two-step approach with one kissing inflation after initial stenting of the side branch and crush with a balloon in the main vessel and a second, or FKBD, after the main vessel stent is placed (the double kissing crush technique). As noted above, this technique has shown benefit over provisional stenting in complex left main coronary artery disease with true distal bifurcation stenosis involving both the left anterior descending and circumflex origins

There is no consensus on which two-stent technique is preferred in the treatment of non-left main bifurcation lesions since most trials have not shown a planned two-stent approach to be superior to stenting of the main branch and rescue of the side branch with balloon angioplasty as needed. It is our practice to avoid side branch stents whenever possible. Regardless of technique, we recommend final kissing balloon inflation for optimal stent deployment whenever side branch stenting is required. Development of specially designed bifurcation stents may offer promise in the treatment of these complex lesions.

Left main disease — Among patients with left main disease, a distal bifurcation lesion requiring a two-stent approach has been associated with higher rates of angiographic restenosis and target lesion revascularization after PCI with DES. This issue is discussed separately.

Small coronary arteries — In general, and irrespective of the device used for PCI, the risk of restenosis after PCI is greater for small compared with large coronary arteries. For most patients who need PCI of one or more lesions in a small coronary artery (≥2 to <3 mm), we use either a second-generation DES or a drug-coated balloon. Drug-coated balloons are not available in the United States.

Randomized trials before the availability of DES suggested that bare-metal stenting in small coronary arteries did not improve long-term outcomes compared to conventional balloon angioplasty, provided that dilatation produced a satisfactory initial result. Stents were beneficial if the results of balloon angioplasty were suboptimal with a persistent significant residual stenosis. The efficacy of the first-generation sirolimus stent compared to bare-metal stents in small coronary arteries was evaluated in three randomized trials, E-SIRIUS, SES-SMART, and TAXUS V. These relatively small studies, E-SIRIUS and SES SMART, found that a DES was associated with significant reductions in restenosis within the lesion ≥50 percent diameter (6 versus 42 percent) and the rate of target vessel revascularization (4 versus 21 percent).

In all studies, the risk of restenosis is lower with second compared with first-generation DES. We have no reason to believe this observation would be different in small coronary arteries.

Drug-coated balloons (DCB) are used in patients with DES or bare metal stent restenosis. Small studies have compared DCB with DES. In the BASKET-Small 2 all-comer population trial, 382 patients with de novo lesions less than 3 mm in diameter were randomly assigned to receive angioplasty with DCB or implantation of a second-generation DES  After 12 months, there was no difference in the rate of the combined outcome of cardiac death, non-fatal MI, and target-vessel revascularization (7.5 versus 7.3 percent; hazard ratio 0.97, 95% CI 0.58-1.64; p value for noninferiority, 0.0217).

At least two newer generation DES designed for very small vessels have been approved.

Large coronary arteries — When evaluating outcomes in patients with large coronary arteries (≥3.0 mm in diameter), two points should be kept in mind:

●The rate of target lesion revascularization (TLR) is lower in large compared to small coronary arteries after stenting with either bare-metal stents or DES.

●In the broad population of patients who undergo PCI with stenting, DES reduce the rate of TLR compared to bare-metal stents, while the risks of death and MI are similar. 

In the subset of patients with large coronary arteries (≥3.0 mm in diameter), we believe evidence allows for the following conclusions regarding efficacy and safety comparing DES to BMS:

●The rate of TLR is equivalent or lower with DES compared to bare-metal stents, but the lower TLR rate in larger vessels makes the absolute benefits lower.

●The issue of the relative rate of harm between DES and bare-metal stents has not been adequately addressed

As the benefit from a reduction in TLR with DES compared to bare-metal stents declines in large vessels, any potential increase in risk associated with the use of DES becomes increasingly important. Retrospective analyses have raised the possibility of a possible increase in risk (cardiac death or MI) with DES in these vessels. The BASKET-PROVE trial attempted to directly address this issue by randomly assigning 2314 patients needing stents 3.0 mm or greater in diameter to receive sirolimus-eluting stents, everolimus-eluting stents, or bare-metal stents. While the rate of the primary endpoint (composite of death from cardiac causes or nonfatal MI at two years) was lower with the two DES (2.6 versus 3.2 versus 4.8 percent for sirolimus-eluting stents, everolimus-eluting stents, and bare-metal stents, respectively), these differences did not achieve statistical significance. This was due in part to unexpectedly low event rates, causing the trial to be underpowered to address the issue. Based on these data and evidence for improved safety and effectiveness for newer-generation DES in other lesions, we prefer DES over BMS in large vessels as long as DES can accommodate the vessel diameter.

Acute vessel closure or dissection — Stenting is the treatment of choice for either acute or threatened closure complicating PTCA and for the treatment of dissection; the goal is to restore TIMI 3 flow. In addition, acute or threatened closure may complicate predilation, stent deployment, or postdilation during a planned stent procedure and require the placements of additional stents to achieve optimal results. Failure to adequately restore flow or leaving untreated dissections significantly increases the risk for subacute thrombosis.

For treatment of acute closure or extensive dissections, the operator must consider other factors that may jeopardize the final result, including the relative size of the vessel, the inflow of blood into the treated segment, and the distal runoff. When either the flow into the artery or distal runoff is compromised, there is an increased risk for acute and subacute stent thrombosis, which may negate the beneficial effects of additional stenting. Smaller caliber vessels treated with smaller diameter stents also have an increased likelihood for subacute thrombosis compared to larger vessels treated with larger diameter stents.

Emergency surgery may be required in some situations, such as dissection of the left main artery or significant bifurcations, refractory thrombosis, loss of guidewire access, or inability to perform stenting.

Population Reference No. 1 & 2 Policy Statement

Percutaneous coronary transluminal angioplasty is considered for payment in the treatment of acute myocardial infarction as an alternative method for patients who do not have contraindications for thrombolysis.

Coronary transluminal percutaneous angioplasty is considered for payment as the first option for patients with contraindications for thrombolysis such as cardiogenic shock, advanced age, or a previous history of coronary bypass ”.

Supplemental Information

Practice Guidelines and Position Statements

American Heart Association (AHA): Scientific statement on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome, update (2018)

●Choosing Wisely: Avoid coronary angiography in post-coronary artery bypass graft (CABG) and post-PCI patients who are asymptomatic, or who have normal or mildly abnormal stress tests and stable symptoms not limiting quality of life (2014, updated 2018)

●Choosing Wisely: Avoid PCI in stable, asymptomatic patients with normal or only mildly abnormal adequate stress test results (2014, updated 2018)

●American College of Cardiology (ACC)/American Association for Thoracic Surgery (AATS)/AHA/American Society of Echocardiography (ASE)/American Society of Nuclear Cardiology (ASNC)/Society for Cardiovascular Angiography and Interventions (SCAI)/Society of Cardiovascular Computed Tomography (SCCT)/Society of Thoracic Surgeons (STS): Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease (2017)

●ACC/AATS/AHA/ASE/ASNC/Heart Rhythm Society (HRS)/SCAI/SCCT/Society for Cardiovascular Magnetic Resonance (SCMR)/STS: Appropriate use criteria for multimodality imaging in valvular heart disease (2017)

●ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS: Appropriate use criteria for coronary revascularization in patients with acute coronary syndromes (2016)

●ACC/AHA: Guideline on duration of dual antiplatelet therapy in patients with coronary artery disease, focused update (2016)

●ACC/AHA/SCAI: Primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction, focused update (2015)

●ACC/AHA: Guideline for the management of patients with non–ST-elevation acute coronary syndromes (2014)

●ACC/AHA/ATS/Preventive Cardiovascular Nurses Association (PCNA)/SCAI/STS: Guideline for the diagnosis and management of patients with stable ischemic heart disease (2014)

●AHA/ACC/HRS: Guideline for the management of patients with atrial fibrillation (2014)

●American College of Cardiology Foundation (ACCF)/AHA/ASE/ASNC/Heart Failure Society of America (HFSA)/HRS/SCAI/SCCT/SCMR/STS: Multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease, 2013 (published 2014)

●Choosing Wisely: Avoid performing routine stress testing after percutaneous coronary intervention (PCI) without specific clinical indications (2014)

●SCAI/ACC/AHA: Expert consensus document on percutaneous coronary intervention without on-site surgical backup, update (2014)

●ACC/AHA/SCAI/American Medical Association (AMA)/National Committee for Quality Assurance (NCQA): Performance measures for adults undergoing percutaneous coronary intervention (2013)

●ACCF/American College of Radiology (ACR)/ASE/ASNC/SCCT/SCMR: Appropriate utilization of cardiovascular imaging in heart failure (2013)

●ACCF/AHA: Guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction, focused update (2012)

●ACCF/AHA: Guideline for the management of ST-elevation myocardial infarction, 2013 (published 2012)

●ACCF/AHA/SCAI: Guideline for percutaneous coronary intervention (2011)

●ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR: Appropriate use criteria for cardiac computed tomography (2010)

●ACC/AHA: Guidelines for the management of patients with ST-elevation myocardial infarction, focused update (2009)

●ACC/AHA: Performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction (2008)

●ACC/AHA: Statement on performance measurement and reperfusion therapy (2008)

●AHA: Scientific statement on assessment of coronary artery disease by cardiac computed tomography (2006)

Medicare National Coverage

CMS National Coverage Determination (NCD) Related NCD: NCD 20.7 Percutaneous Transluminal Angioplasty (PTA)

References

1. TEC Assessments 1995: Tab 35

2.Percutaneous coronary intervention with intracoronary stents: Overview; Authors:J Dawn Abbott, MD, FACC Donald Cutlip, MD; Section Editor: Stephan Windecker, MD Deputy Editor: Gordon M Saperia, MD Contributor Disclosures; All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through Sep 2020. | This topic last updated: Jun 03, 2020.

Codes

Applicable Modifiers

Policy History