BlueCross BlueShield of Tennessee Medical Policy Manual

Cardiovascular System

• Acoustic Cardiography

• Angioplasty and/or Stenting for Intracranial Arterial Disease

• Automatic Implantable Cardioverter Defibrillator for the Prevention of Sudden Death

• Baroreflex Stimulation Devices

• Biventricular Pacemakers for the Treatment of Heart Failure

• C1 Esterase Inhibitor

• Chelation Therapy

• Computed Tomography (CT) Perfusion Imaging

• Computed Tomography Angiography for Coronary Artery Evaluation

• Computed Tomography to Detect Coronary Artery Calcification

• Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease

• Drug-Eluting Stents for the Prevention and Management of Restenosis

• Eculizumab

• Electrocardiographic Body Surface Mapping

• End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease

• Endovascular Stent Grafting for Treatment of Abdominal Aortic Aneurysm and Thoracic Aortic Aneurysm and Dissections

• Enhanced External Counterpulsation (EECP)

• Epoprostenol Sodium for the Treatment of Pulmonary Hypertension

• Gene Expression Testing for Coronary Artery Disease

• Genetic Testing for Congenital Cardiac Channelopathies

• High Sensitivity C-Reactive Protein (hs-CRP) Testing for Cardiovascular Disease (CVD)

• Home Apnea Monitoring / Home Cardiorespiratory Monitoring

• Home Spirometry

• Homocysteine Testing in the Screening, Diagnosis, and Management of Dyslipidemia and Cardiovascular Disease

• Intracardiac Electrophysiologic Studies

• Intravascular Ultrasound (IVUS) Imaging of Coronary Arteries

• KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

• Laboratory Tests for Heart Transplant Rejection

• Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

• Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease

• Low-Density Lipid Apheresis

• Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk

• Measurement of Serum Intermediate Density Lipoproteins (Remnant Lipoproteins)

• Mechanical Embolectomy for Treatment of Acute Stroke

• Microvolt T-Wave Alternans Testing for Cardiac Arrhythmias

• Minimally Invasive Coronary Artery Bypass Graft Surgery

• Non-Invasive Medical Devices for Measuring Arterial Elasticity for Cardiovascular Disease

• Partial Left Ventriculectomy for the Treatment of End-Stage Congestive Heart Failure and Dilated Cardiomyopathy

• Pegloticase

• Percutaneous Transluminal Angioplasty of the Aortic Arch Vessels with or without stenting (Brachiocephalic, Carotid, Subclavian, & Vertebral arteries), and of Coarctation of the Aorta

• Percutaneous Transluminal Septal Myocardial Ablation

• Plethysmography

• Post Heart Transplant Endomyocardial Biopsy

• Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

• Signal Averaged Electrocardiography (SAECG)

• Stem Cell Therapy for Peripheral Artery Disease

• Surgical Ventricular Restoration

• Thoracic Electrical Bioimpedance and Inert Gas Rebreathing Devices in the Outpatient Setting

• Three-Dimensional Magnetic Navigation Mapping System for Radiofrequency Ablation for the Treatment of Arrhythmias

• Total Body and Regional Hypothermia

• Transcatheter Closure Devices for Cardiac Defects

• Transtelephonic Electrocardiographic Monitoring

• Treprostinil for the Treatment of Pulmonary Hypertension

• Ultrasonographic Measurements of Carotid Intima-Medial Thickness (CIMT) as an Assessment of Subclinical Atherosclerosis

• Varicose Vein Treatments for the Lower Extremities

• Ventricular Assist Devices

• Wearable Cardioverter Defibrillator for the Prevention of Sudden Death

• Wireless Pressure Sensors in Endovascular Aneurysm Repair

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