CommercialCoverageMedium impact
Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) (CPB 0558, reviewed 2026-02-19)
Aetna·Cardiology, Cardiothoracic Surgery, Internal Medicine·Surgery
Effective date
Feb 19, 2026
We identified it
Aug 13, 2026
Summary
Aetna has issued a fresh clinical policy (CPB 0558, reviewed 2026-02-19) establishing medical necessity criteria for Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) in adults and young patients with hypertrophic obstructive cardiomyopathy. The policy covers CPT 93583 when strict selection criteria are met, but designates ultrasound-guided PTSMA and SESAME procedures as experimental/investigational and not covered. Billing teams must immediately verify patient eligibility against the detailed clinical criteria before submitting claims.
Action Required
By 2026-02-19: Billing team must update prior authorization workflows and billing system edits to enforce Aetna's PTSMA coverage criteria. (1) Configure system to require prior authorization for CPT 93583 with ICD-10 I42.1 (obstructive hypertrophic cardiomyopathy). (2) Implement validation rules requiring documentation of: severe symptoms ≥6 months despite optimal medical therapy, NYHA class III or IV status, classical asymmetric subaortic HOCM on echocardiography, LV wall thickness >13mm (adults) or >15mm (athletes), systolic anterior motion of mitral valve, LVOT gradient specifications (≥30mm Hg at rest or ≥60mm Hg with stress, or ≥50mm Hg at rest/≥100mm Hg under stress for less severe symptoms), and absence of coronary artery disease. (3) Deny claims for ultrasound-guided PTSMA, SESAME procedure, and ICD-10 I42.2 (other hypertrophic cardiomyopathy) as these are designated experimental/investigational. (4) Add medical record request templates requesting echocardiography results, cardiac imaging, medication history, and NYHA classification documentation. Failure to validate these criteria will result in claim denials. Providers must document all required clinical elements in the medical record to support medical necessity.