Excimer Laser Coronary Angioplasty (ELCA)

POLICY NUMBER

L.7.01.406

DESCRIPTION

In the 1980s, excimer laser angioplasty was developed as an alternative method of percutaneous angioplasty, with the objective of reducing the high rate of restenosis associated with other angioplasty or stenting techniques. Excimer laser coronary angioplasty (ELCA) is a procedure that utilizes an intravascular catheter system to deliver high-energy laser light to atherosclerotic lesions that are causing stenosis or occlusion of native coronary arteries, vein grafts placed at previous coronary artery bypass surgery, or stainless steel intracoronary stents, while producing relatively little thermal damage to the vessel wall. ELCA is usually performed in combination with balloon angioplasty and is intended as a minimally invasive alternative to open surgical revascularization for patients with atherosclerotic coronary lesions.

POLICY

Excimer laser coronary angioplasty (ELCA) for the treatment of atherosclerotic lesions that are causing stenosis or occlusion of native coronary arteries, vein grafts placed at coronary artery bypass surgery, or stainless steel intracoronary stents is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

8/2002: Approved by Medical Policy Advisory Committee (MPAC)

12/19/2003: Code Reference section completed

10/16/2006: Policy reviewed, no changes

08/25/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure code 39.59 from the Code Reference section. Added ICD-9 procedure code 36.09.

06/01/2016: Policy number L.7.01.406 added. Investigative definition updated in Policy Guidelines section.

09/30/2016: Code Reference section updated to add new ICD-10 procedure codes 02C03Z6, 02C13Z6, 02C33Z6, and 02C33Z6.

10/14/2022: Policy reviewed; no changes.

10/18/2023: Policy reviewed. Policy statement unchanged. Sources updated.

12/03/2024: Policy reviewed; no changes.

SOURCE(S)

Cutlip, D. Specialized revascularization devices in the management of coronary heart disease. UpToDate. https://www.uptodate.com/contents/specialized-revascularization-devices-in-the-management-of-coronary-heart-disease?search=excimer%20laser%20coronary%20angioplasty&source=search_result&selectedTitle=1~2&usage_type=default&display_rank=1 . Last accessed September 2023.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

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