Diagnostic cardiac catheterization involves the passage of a catheter into the right heart, left heart, or both, usually from a peripheral blood vessel (e.g., femoral artery or vein). The elements of diagnostic cardiac catheterization may include: 1) recording intracardiac and intravascular pressures, 2) injecting contrast material, 3) obtaining samples for blood gas analysis and/or cardiac output measurements, 4) placing electrodes, and 5) performing endomyocardial biopsy. Angiography during cardiac catheterization is performed by catheter placement within chambers, coronary arteries, conduits, grafts, or great vessels with injection of contrast material for the purpose of obtaining images. These techniques are utilized when there is a need to confirm the presence of a clinically suspected condition, define its anatomical and physiological severity, and determine the presence of associated conditions. This need most commonly arises when the clinical assessment suggests that the patient may benefit from an interventional procedure or cardiac surgery. The physician then documents the conduct and evaluation of these procedures in a report.

This policy does not apply to cardiac catheterizations performed for the study of congenital cardiac anomalies.

Diagnostic cardiac catheterization is covered when medically necessary for the evaluation of patients with known or suspected cardiac disease when this information will be useful in making management decisions and the information being sought cannot be obtained from appropriate noninvasive studies.

Indications for left heart catheterization with or without angiography, as appropriate:

1. Clinically significant acquired left heart disease under consideration for surgical correction.
2. Suspicion of coronary artery disease (CAD) based on findings from noninvasive cardiac studies, such as routine ECG, exercise stress test, and echocardiogram or myocardial perfusion and cardiac blood pool imaging at rest and during stress.
3. Symptoms indicative of CAD that persist when findings from noninvasive cardiac studies were equivocal or nondiagnostic, and are not adequately responsive to medical treatment. Symptoms indicative of CAD may be represented by typical angina (e.g., exertional chest pain), atypical angina (e.g., arm or jaw pain, chest pressure or tightness), or anginal equivalent (e.g., shortness of breath).
4. A clinical diagnosis or suspicion of unstable angina (intermediate coronary syndrome) is an appropriate indication for coronary angiography without prior non-invasive testing
5. Acute myocardial infarction - For purposes of this policy, acute myocardial infarction is defined as evidence meeting any two of the following three criteria: a) chest pain (angina) of 30 minutes or greater duration, b) electrocardiographic features in two contiguous leads consistent with the diagnosis, and c) positive cardiac enzyme elevations.
6. Cardiac arrest thought to be due to a cardiac cause.
7. Complications of acute myocardial infarction.
8. Increased operative risk based on findings from noninvasive studies indicative of silent coronary artery disease (CAD) in patients being considered for open heart surgery or major vascular surgery.
9. To identify the cause, extent or degree of left ventricular dysfunction or left heart failure.
10. When determination of the extent of coronary ostium involvement by a disease of the aorta is a factor in the management of the disease.
11. Suspicion of cardiomyopathy, endocarditis or myocarditis.
12. Assessment of cardiac transplant for rejection.
13. Evaluation of significant serious ventricular arrhythmia.

Indications for right heart catheterization with or without angiography, as appropriate:

1. Following acute MI when symptoms and noninvasive cardiac studies suggest the occurrence of a recurrent life-threatening ventricular arrhythmia, heart failure, ventricular aneurysm, ruptured interventricular septum, or tricuspid regurgitation.
2. In the presence of right ventricular dysfunction or right heart failure when noninvasive cardiac studies do not identify the cause, extent or degree of severity.
3. Suspicion of pulmonary arterial system disease (e.g., pulmonary hypertension).
4. Suspicion of pulmonary embolism.
5. Evaluation of unexplained dyspnea when congestive heart failure is the suspected cause.
6. Evaluation of mitral or aortic valvular disease.
7. Risk stratification prior to cardiac transplantation.
8. Clinically significant acquired right heart disease under consideration for surgical correction.
9. Suspicion of cardiomyopathy, endocarditis or myocarditis.
10. Assessment of cardiac transplant for rejection.
11. Determination of cardiac output.

Limitations

1. Diagnostic cardiac catheterization is an integral part of certain invasive therapeutic procedures such as intracoronary stent placement and percutaneous transluminal balloon angioplasty. Separate reimbursement for diagnostic cardiac catheterization on the same day as a therapeutic procedure is allowed only when it represents the initial study to determine the medical necessity for the therapeutic procedure.
   
   
2. Right heart catheterization, performed along with left heart catheterization, coronary angiography, or both, is medically reasonable and necessary when a single disease process appears to affect both sides of the heart, or separate disease processes appear to independently affect each side of the heart.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Services reported for ineligible conditions are considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.

Left heart catheterization with or without angiography (codes 93452, 93454, 93455, 93458, 93459, 93462, 93463, 93464, 93564, 93566, 93567, 93568)

Right heart catheterization (codes 93451, 93463, 93464, 93564, 93566, 93567, 93568)

For combined right and left heart catheterization (codes 93453, 93456, 93457, 93460, 93461, 93462, 93463, 93464, 93564, 93566, 93567, 93568)