Transluminal coronary interventions are appropriately considered in those patients who manifest symptoms or signs of acute coronary insufficiency or manifest symptoms or signs of chronic coronary insufficiency and have not responded adequately to optimized medical therapy. All patients should have objective evidence of myocardial ischemia due to lesions amenable to transluminal intervention.
Transluminal interventions encompass:
  • Balloon dilation.
  • Atherectomy using a number of devices.
  • Coronary artery stent placement.
  • Coronary brachytherapy. (Note: This LCD applies only to the placement of the radiation delivery device for coronary brachytherapy.)
Transluminal interventions are covered only when performed in the inpatient or outpatient hospital setting.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
036X, 045X, 048X
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Insert drug eluting stent, single vessel (Part A only)
Insert drug eluting stent, each additional vessel (Part A only)
Percut coronary thrombectomy
Cath place, cardio brachytx
Insert intracoronary stent
Insert intracoronary stent
Coronary artery dilation
Coronary artery dilation
Coronary atherectomy
Coronary atherectomy add on
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Note: Limited coverage is not being established at this time for CPT code 92974.
Medicare is establishing the following limited coverage for CPT/HCPCS codes G0290, G0291, 92973, 92980, 92981, 92982, 92984, 92995 and 92996:
Covered for:
Acute myocardial infarction of anterolateral wall
Acute myocardial infarction of other anterior wall
Acute myocardial infarction of inferolateral wall
Acute myocardial infarction of inferoposterior wall
Acute myocardial infarction of other inferior wall
Acute myocardial infarction of other lateral wall
Acute myocardial infarction of true posterior wall
Acute myocardial infarction, subendocardial
Acute myocardial infarction of other specified sites
Acute myocardial infarction of unspecified site
Intermediate coronary syndrome
Other acute and subacute forms of ischemic heart disease
Other acute and subacute forms of ischemic heart disease
Angina decubitus
Other and unspecified angina pectoris
Coronary atherosclerosis
Aneurysm of coronary vessels
Other forms of chronic ischemic heart disease
Other specified forms of chronic ischemic heart disease
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.