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Cardiac catheterization prior authorization in coronary artery disease

Updated: Jul 21, 2023

Is Preauth Required? Cardiac catheterization for coronary artery disease may be indicated for diagnosis of, or treatment planning for, patients with anginal syndromes, atypical chest pain syndrome suggesting ischemia, congenital heart disease, following cardiac arrest thought to be due to ischemia or infarction, myocardial infarction, known atherosclerotic or other coronary disease, suspected graft or stent/PTCA closure, Prinzmetal’s angina, coronary shunts and fistulae, cardiac trauma, and for treatment planning in patients undergoing cardiac surgical procedures. Preauthorization may be required in some cases.

Will the claim be denied? Cardiac catheterization for coronary artery disease may be denied if it is performed at the time of cardiac catheterization in the absence of accepted clinical indications that support medical necessity, as mentioned in this LCD.

When is the following treatment medically necessary for the condition specified? Cardiac catheterization is considered medically necessary for coronary artery disease when the patient is experiencing chest pain or an abnormal stress test, when the patient has a known coronary artery obstruction, or when the patient has a known diagnosis of coronary artery disease and has failed a trial of medical therapy.

What would make the following treatment considered medically necessary? Cardiac catheterization is considered medically necessary in the context of coronary artery disease when a patient has severe or difficult to control angina, or if medical management is not effective in the treatment of the patient's condition.

What are the relevant codes for the treatment? The following CPT/HCPCS codes describe cardiac catheterization for coronary artery disease: 92978, 92979, 93451, 93452, 93453, 93454, and 93455. Modifiers should be used to identify the major artery (RC: right coronary artery, LC: left circumflex coronary artery, LD: left anterior descending coronary artery, LM: left main coronary artery, and RI: ramus intermedius). Claims should be linked to the appropriate diagnosis codes (e.g. I25.82 for chronic total occlusion of coronary artery and I31.4 for cardiac tamponade) and the underlying disorder should be reported as a secondary diagnosis.

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