BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for End-Stage Heart Failure

PURPOSE

To establish a basis for determining medical necessity for testing and treatment of end-stage heart failure.

DESCRIPTION

Heart failure occurs when there is an abnormal cardiac function causing the heart to fail to pump blood at a rate required by the metabolizing tissues or when the heart can do so only with elevated filling pressure. The heart's inability to pump a sufficient amount of blood to meet the needs of the body tissues may be due to insufficient or defective cardiac filling and/or impaired contraction and emptying. End-stage heart failure exists when severe symptoms persist after all therapy with ACE inhibitors and/or other vasodilators, diuretics, digoxin and reperfusion procedures have been exhausted.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness in the diagnosis and treatment of end-stage heart failure.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

********* THE FOLLOWING POLICIES HAVE BEEN *********

REVIEWED. PLEASE REFER TO THE POLICY

********* TO DETERMINE MEDICAL APPROPRIATENESS. *********

DIAGNOSTICS:

• Acoustic Cardiography

• Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

• Computed Tomography Angiography for Coronary Artery Evaluation

• Computed Tomography to Detect Coronary Artery Calcification

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

• Intracardiac Electrophysiologic Studies

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

• Post Heart Transplant Endomyocardial Biopsy

• Signal Averaged Electrocardiography (SAECG)

THERAPEUTICS:

• Automatic Implantable Cardioverter Defibrillator for the Prevention of Sudden Death

• Biventricular Pacemakers for the Treatment of Heart Failure

• Enhanced External Counterpulsation (EECP)

• Epoprostenol Sodium for the Treatment of Pulmonary Hypertension

• Implantable Ventricular Assist Devices (VAD) and Total Artificial Hearts (TAH)

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

• 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

• Plasma Exchange

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

• Surgical Ventricular Restoration

• Treprostinil for the Treatment of Pulmonary Hypertension

• Wearable Cardioverter Defibrillator for the Prevention of Sudden Death

ORIGINAL EFFECTIVE DATE:  12/9/1998

MOST RECENT REVIEW DATE:  2/6/2012

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.