Minimally invasive direct coronary artery bypass graft surgery (MIDCAB)(procedure codes S2205, S2206, S2207, S2208, S2209) may be considered medically necessary for the treatment of atherosclerosis. 

MIDCAB performed for other conditions is considered not medically necessary. A participating, preferred, or network 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 should be maintained in the provider's records.

Minimally invasive coronary artery surgery may involve other surgical techniques that include the use of robotic surgical systems. Other techniques for minimally invasive coronary artery bypass graft surgery, that can include the use of robotics and are not performed under direct visualization, are experimental/ investigational and therefore, non-covered. There is insufficient evidence to conclude that techniques that can include the use of robotics and are not performed under direct visualization, provide comparable outcomes to conventional open surgical procedure. A participating, preferred, or network provider can bill the member for the non-covered service. As there isn't a specific procedure code or codes to define other techniques for minimally invasive coronary artery bypass graft surgery, that can include the use of robotics and are not performed under direct visualization, claims for these services should be billed utilizing the not otherwise classified code 33999 with the description of the service noted on the claim descriptor for this NOC code.

Please refer to Medical Policy Bulletin, M-50, for additional information on robotic surgery.

Place of Service: Inpatient

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 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. 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.

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.

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Blue Cross and Blue Shield Association. Minimally Invasive Coronary Artery Bypass Graft Surgery. Medical Policy Reference Manual 7.01.62. Issued April, 2010.