Archived Policies - Surgery


Dynamic Cardiomyoplasty

Number:SUR707.005

Effective Date:10-15-2017

End Date:09-30-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

Dynamic cardiomyoplasty is considered experimental, investigational, and/or unproven.

Description:

Dynamic cardiomyoplasty is a surgical technique that uses paced, conditioned skeletal muscle to reinforce the failing heart. Briefly, the surgical procedure is as follows: the left latissimus dorsi, the muscle most commonly used, is dissected from its surrounding tissues, preserving the neurovascular bundle. The muscle is then transposed into the left hemithorax through a window created by partial resection of an adjacent rib. A median sternotomy is then performed to provide access to the heart. The latissimus dorsi is wrapped around the ventricular surface. After a 2-week postoperative period to allow for adhesion between the latissimus dorsi and heart, the skeletal muscle is electrostimulated and conditioned to induce fatigue resistance. An epicardial lead attached to the right ventricle, pacing leads attached to the muscle itself, and an implanted pacemaker which provides the electrostimulation. The conditioning program requires about 2 to 3 months. After that time the skeletal muscle graft can be paced synchronously with the heart.

Regulatory Status

Rationale:

Dynamic cardiomyoplasty has been investigated as an alternative to medical therapy or as an alternative/bridge to heart transplantation in patients with congestive heart failure, particularly given the shortage of donor hearts for transplant. Thus pertinent outcomes include improvement in hemodynamics of the heart, patient functional capacity, and long-term survival rates compared to medical management or transplantation.

Furnary and colleagues reported on a multicenter trial of cardiomyoplasty in 68 patients, comparing outcomes to a non-randomized group of patients with heart failure. (1) There were modest improvements in various hemodynamic measures, such as left ventricular ejection fraction. Modest improvements were also noted in the New York Heart Association Function class and activity of daily living score. However, there was no difference in 12-month mortality between the 2 groups. This lack of effect on mortality may be related to the fact that cardiomyoplasty does not address the underlying cardiac pathology, and patients remain at risk for lethal arrhythmias, a major cause of death in patients with congestive heart failure. Some investigators have hypothesized that any improvement may be primarily related to a simple girdling effect of the wrapped latissimus dorsi muscle, which interrupts further dilation of the heart. If this is true, then the primary effect of cardiomyoplasty occurs during diastole, not systole, and pacing of the latissimus dorsi may be unnecessary. In addition, there may be simpler methods to provide a girdling effect. It should also be noted that this study focused on patients with Class III heart failure, since prior studies had shown an unacceptably high mortality rate among patients with Class IV heart failure undergoing cardiomyoplasty. Patients with Class III heart failure are also those who respond well to medical management. (2-6)

Dynamic cardiomyoplasty requires the use of a unique pacing device, the Cardiomyostimulator, which has not received final U.S. Food and Drug Administration (FDA) approval.

2013 Update

As of July 2013, no evidence could be located that showed the FDA approval status of the Cardiomyostimulator has changed. A search of peer reviewed literature through July 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2015 Update

UpToDate 2015 notes the following regarding dynamic cardiomyoplasty (8). “Early enthusiasm was driven by improvements in functional capacity and ventricular remodeling, but long-term outcome data were limited. A large, randomized clinical trial of cardiomyoplasty in New York Heart Association class III patients was prematurely terminated because of poor enrollment and modest clinical benefit. These data suggested that those who could survive the operation did not need it, and those who did need it could not survive it. For these reasons, cardiomyoplasty is no longer performed for the management of heart failure (HF).”

2017 Update

A search of peer reviewed literature through July 2017 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

33999

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Furnary AP, Jessup FM, et al. Multicenter trial of dynamic cardiomyoplasty for chronic heart failure. J Am Coll Cardiol. 1996; 28(5):1175–80. PMID: 8890812

2. Leier CV. Cardiomyoplasty: is it time to wrap it up? J Am Coll Cardiol 1996; 28(5):1181–2. PMID: 8890813

3. Letsou GV, Austin L, Grandjean PA et al. Dynamic cardiomyoplasty. Cardiol Clin. 1995; 13(1):121–4. PMID: 7796426

4. Silverman NA. Invited letter concerning: clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J Thorac Cardiovasc Surg. 1995; 109(2):397–8. PMID: 7853897

5. Moreira LF, Stolf NA, et al. Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J Thorac Cardiovas Surg. 1995; 109(2):353–63. PMID: 7853887

6. Kass DA, Baughman KL, et al. Reverse remodeling from cardiomyoplasty in human heart failure. External constraint versus active assist. Circulation. 1995; 91(9):2314–8. PMID: 7729016

7. Dynamic Cardiomyoplasty (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2:2010).

8. Fang, JC, et al. Surgical management of heart failure. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. September 2015 (Accessed August 2017)

Policy History:

DateReason
10/15/2017 Document updated with literature review. Coverage unchanged.
10/1/2016 Reviewed. No changes.
2/1/2016 Document updated with literature review. Coverage unchanged.
9/15/2014 Reviewed. No changes.
10/15/2013 Literature reviewed. No changes.
3/15/2008 Policy reviewed without literature review; new review date only
2/1/2007 Revised/Updated Entire Document
4/1/1999 Revised/Updated Entire Document
5/1/1996 Revised/Updated Entire Document
7/1/1993 New Medical Document

Archived Document(s):

Title:Effective Date:End Date:
Dynamic Cardiomyoplasty10-15-201709-30-2018
Dynamic Cardiomyoplasty10-01-201610-14-2017
Dynamic Cardiomyoplasty02-01-201609-30-2016
Dynamic Cardiomyoplasty09-15-201401-31-2016
Dynamic Cardiomyoplasty10-15-201309-14-2014
Dynamic Cardiomyoplasty03-15-200810-14-2013
Dynamic Cardiomyoplasty02-01-200703-14-2008
Dynamic Cardiomyoplasty04-01-199901-31-2007
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