Transmyocardial laser revascularization may be considered medically necessary for individuals with class III or IV angina, who are not candidates for coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty surgery, who meet ALL of the following criteria:
Presence of class III or IV angina refractory to medical management
Documentation of reversible ischemia
Left ventricular ejection fraction greater than 30%
No evidence of recent myocardial infarction or unstable angina within the last 21 days
No severe comorbid illness such as chronic obstructive pulmonary disease.
Transmyocardial laser revascularization may be considered medically necessary as an adjunct to coronary artery bypass graft in those individuals with documented areas of ischemic myocardium that are not amenable to surgical revascularization.
Transmyocardial laser revascularization is considered investigational for all other indications not meeting the above criteria.
Percutaneous transmyocardial laser revascularization is considered investigational.
