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MP 7.01.65 Chronic Pulmonary Thromboendarterectomy

Medical Policy
Section
Surgery
Original Policy Date
4/1/98
Last Review Status/Date
Reviewed with literature search/3:2003
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Chronic obstruction of the large pulmonary arteries by persistent (> 6 months) emboli is a potentially treatable cause of pulmonary hypertension and right-sided heart failure. Fibrotic masses in major pulmonary arteries may result when pulmonary thrombi fail to resolve normally, ultimately leading to pulmonary hypertension. Other factors such as age of the embolus or defects in the fibrinolytic system may also be important. In many cases there is no documented history of embolization. Early diagnosis is difficult since the patients are rarely symptomatic until the development of pulmonary hypertension and right-sided heart failure. Even then diagnosis can be difficult and depends on a high index of suspicion, ventilation/perfusion scans, and careful and experienced interpretation of pulmonary angiograms.

Over the last 2 decades, Moser and colleagues at the University of California at San Diego (UCSD) have developed a technique for surgical removal of the obstructing thromboemboli, as a curative alternative to lung transplantation. The surgery involves cardiopulmonary bypass, and since the obstruction is typically bilateral, the surgical approach requires a median sternotomy. Removal of the organized thrombus requires meticulous dissection in a bloodless field, which in turn requires profound hypothermia with periods of cardiac arrest. In addition, a vena cava filter is usually placed to prevent recurrence of emboli (CPT code 75940).


Policy

Pulmonary thromboendarterectomy of chronic thromboembolic obstruction due to fibrosed pulmonary emboli involving the pulmonary arteries may be considered medically necessary.

Typical patient selection criteria for this procedure include New York Heart Association Class III or IV, a mean pulmonary artery pressure above 30 mm Hg, or a pulmonary vascular resistance of greater than 300 dynes/sec/cm2.


Policy Guidelines

CPT code 33910 may be used for this procedure. This code, defined as pulmonary artery embolectomy with cardiopulmonary bypass, is also used to describe acute pulmonary embolectomy, which is typically a surgical emergency.


Benefit Application

BlueCard/National Account Issues

This is a specialized procedure that may require out of network referral.


Rationale

In 1993 Jamieson and colleagues published the results of pulmonary thromboendarterectomy in 150 cases performed by one surgeon. (1) A total of 13 patients died for an overall in-hospital mortality of 8.7%. Immediate declines in the hemodynamic measures of surviving patients were highly significant: the mean pulmonary artery pressure dropped from 48.5 to 28.9 mm Hg and the pulmonary vascular resistance dropped from 936 to 299.4 dynes/sec/cm2. Of 150 patients who returned for repeat hemodynamic testing from 6 to 24 months after the surgery, hemodynamic improvement remained stable in 47. (2) One year after surgery, New York Heart Association (NYHA) classifications were recorded for 117 patients of the total 150. Preoperatively, the distributions for Class I through IV were as follows: 0, 5, 49, and 63. One year after surgery the distribution was 85, 26, 6, and 0. Therefore, preoperatively 95% of the patients were NYHA Class III or IV, whereas postoperatively 95% of patients were in NYHA Class I or II.

The bulk of the literature comes from physicians at the University of California at San Diego (UCSD). These physicians emphasize the importance of the learning curve of this challenging surgery, and the importance of having a dedicated staff. Therefore patients should be aware of the institutional experience with this surgery.

2003 Update
 
A literature search was performed on the MEDLINE database for the period of 1998 through June 2003. No literature was identified that would prompt reconsideration of this policy; therefore the policy statement is unchanged. The reported literature continues to report favorable results, although the literature continues to be primarily authored by physicians from UCSD. (3-5)

References:

  1. Jamieson SW, Auger WR, Fedullo PF et al. Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period. J Thorac Cardiovasc Surg 1993; 106(1):116-27.
  2. Moser KM, Auger WR, Fedullo PF et al. Chronic thromboembolic pulmonary hypertension: clinical picture and surgical treatment. Eur Respir J 1992; 5(3):334-42.
  3. Thistlewaite PA, Mo M, Madani MM et al. Operative classification of thromboembolic disease determines outcome after pulmonary endarterectomy. J Thorac Cardiovasc Surg 2002; 124(6):1203-11.
  4. Jamieson SW, Nomura K. Indications for and the results of pulmonary thrombendarterectomy for thromboembolic pulmonary hypertension. Semin Vasc Surg 2000; 13(3):236-44.
  5. Archibald CJ, Auger WR, Fedullo PF et al. Long-term outcome after pulmonary thromboendarterectomy. Am J Respir Crit Care Med 1999; 160(2):523-8.

 

Codes

Number

Description

CPT 

33910–33915 

Pulmonary artery embolectomy; with or without cardiopulmonary bypass, code range 

 

33916 

Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass 

 

75940 

Percutaneous placement of IVC filter, radiological supervision and interpretation 

ICD-9 Procedure 

38.05 

Incision of thoracic vessels (includes embolectomy and thrombectomy) 

 

38.15 

Endarterectomy of thoracic vessels 

 

39.61 

Extracorporeal circulation (as appropriate) 

ICD-9 Diagnosis 

415.0 

Acute cor pulmonale 

 

416.0 

Primary pulmonary hypertension 

 

416.8 

Other chronic pulmonary heart diseases (includes secondary pulmonary hypertension) 

 

428.0 

Congestive heart failure (includes right heart failure) 

HCPCS 

L8670 

Vascular graft material, synthetic, implant 

Type of Service 

Surgery 

Place of Service 

Inpatient 


Index

Endarterectomy, pulmonary
Pulmonary emboli, chronic
Pulmonary thromboendarterectomy


Policy History

Date Action Reason
04/01/98 Add to Surgery section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed with literature review; policy unchanged


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