Minimally Invasive Coronary Artery Bypass Graft Surgery
DESCRIPTION
There are currently variations on techniques that are classified as “minimally invasive” coronary artery bypass graft (CABG) surgery. The surgery can be done under direct vision, with a mini-sternotomy or a mini-thoracotomy approach. These types of direct procedures where the vascular anastomoses are hand-sewn under direct vision have been termed minimally invasive direct coronary artery bypass (MIDCAB). MIDCAB is performed without cardiopulmonary bypass by slowing the heart rate to 40 beats per minute to minimize motion in the surgical field. The performance of a coronary bypass on a beating heart increases the technical difficulty of the procedure, particularly in terms of the quality of the vessel anastomosis. In MIDCAB, the predominant re-anastomosis performed uses the native internal mammary artery to bypass the left anterior descending (LAD) coronary artery. Bypass of the right coronary artery may also be possible in patients with suitable anatomy.
The surgery can also be performed endoscopically, whereby the internal structures are visualized on a video monitor, and the entire procedure is performed without direct visualization of the operative field. Cardiopulmonary bypass may or may not be used with this technique. This variation of minimally invasive CABG is called port access coronary artery bypass (PACAB) or total endoscopic coronary artery bypass (TECAB). Using this approach, theoretically, all sides of the heart can be approached. In many instances, only a single bypass of the LAD artery is performed, although multivessel bypass of the left and right coronary artery has been performed.
POLICY
Minimally invasive coronary artery bypass graft surgery for the treatment of occluded coronary vessels is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Minimally invasive coronary artery bypass graft surgery for the treatment of occluded coronary vessels, including but not limited to, the following: port access coronary artery bypass (PACAB) or total endoscopic coronary artery bypass (TECAB) is considered investigational.
MEDICAL APPROPRIATENESS
Minimally invasive coronary artery bypass graft surgery is considered medically appropriate if ALL the following criteria are met:
Minimally invasive direct coronary artery bypass graft surgery (MIDCAB) is performed
Documentation of occluded coronary vessels must be submitted
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Available studies do not allow determination of the comparative efficacy of TECAB or PACAB. Clinical trials were not identified that directly compare these newer techniques with alternatives such as conventional CABG, MIDCAB, or PTCA. Therefore, existing data are not sufficient to determine if this approach improves net health outcomes.
SOURCES
Aziz, O., Rao, C., Panesar, S. S., Panesar, S. S., Jones, C., Morris, S., et al. (2007). Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularization for isolated lesions of the left anterior descending artery. British Medical Journal, 334 (7594), 617-624.
BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2010). Minimally invasive coronary artery bypass graft surgery (7.01.62). Retrieved January 4, 2011 from BlueWeb. (24 articles and/or guidelines reviewed)
Jaffery, Z., Kowalski M., Weaver, W. D., & Khanal, S. (2007). A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery. European Journal of Cardiothoracic Surgery, 31 (4), 691-697. Abstract retrieved January 6, 2011 from PubMed.
Kofidis, T., Emmert, M. Y., Paeschke, H. G., Emmert, L. S., Zhang, R., & Haverich, A. (2009). Long-term follow-up after minimal invasive direct coronary artery bypass grafting procedure: A multi-factorial retrospective analysis at 1000 patient-years. Interactive Cardiovascular and Thoracic Surgery, 9 (6), 990-994.
ORIGINAL EFFECTIVE DATE: 5/1/2000
MOST RECENT REVIEW DATE: 6/11/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.