BlueCross and BlueShield of Montana Medical Policy/Codes
Dynamic Cardiomyoplasty
Chapter: Surgery: Procedures
Current Effective Date: October 25, 2013
Original Effective Date: October 25, 2013
Publish Date: July 25, 2013
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 provide 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.

Cardiomyoplasty requires the use of a unique pacemaker manufactured by Medtronic (the Cardiomyostimulator), which has not yet received approval from the U.S. Food and Drug Administration (FDA). Thus at the present time, cardiomyoplasty is only offered in the context of an FDA investigational device exemption (IDE) trial.

Policy

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.

Coverage

Dynamic cardiomyoplasty is considered experimental, investigational, and unproven.

Rationale

At the present time dynamic cardiomyoplasty is being 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.

Most recently, Furnary and colleagues have 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)

Finally, at the present time, dynamic cardiomyoplasty requires the use of a unique pacing device, the Cardiomyostimulator, which has not received final 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.

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.

ICD-9 Codes

Experimental, investigational and unproven for all diagnoses.

ICD-10 Codes

Experimental, investigational and unproven for all diagnoses.

Procedural Codes: 33999
References
  1. Furnary AP, Jessup FM, Moreira LP. Multicenter trial of dynamic cardiomyoplasty for chronic heart failure. J Am Coll Cardiol 1996; 28(5):1175–80.
  2. Leier CV. Cardiomyoplasty: is it time to wrap it up? J Am Coll Cardiol 1996; 28(5):1181–2.
  3. Letsou GV, Austin L, Grandjean PA et al. Dynamic cardiomyoplasty. Cardiol Clin 1995; 13(1):121–4.
  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.
  5. Moreira LF, Stolf NA, Bocchi EA et al. Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J Thorac Cardiovas Surg 1995; 109(2):353–63.
  6. Kass DA, Baughman KL, Pak PH et al. Reverse remodeling from cardiomyoplasty in human heart failure. External constraint versus active assist. Circulation 1995; 91(9):2314–8.
  7. Dynamic Cardiomyoplasty—Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2:2002).
History
July 2013  New BCBSMT medical policy.  Dynamic cardiomyoplasty is considered experimental, investigational, and unproven. 
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Dynamic Cardiomyoplasty