Aetna modified CPB 0558 governing percutaneous transluminal septal myocardial ablation (PTSMA) coverage policy, effective February 21, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated CPB 0558 — the coverage policy controlling PTSMA by alcohol-induced septal branch occlusion for hypertrophic obstructive cardiomyopathy (HOCM). The primary billing code affected is CPT 93583, which covers percutaneous transcatheter septal reduction therapy including alcohol septal ablation. HCPCS C1886 (catheter, extravascular tissue ablation) also falls under this policy. If your practice or facility bills for HOCM interventions, this update changes the documentation requirements your team needs to support prior authorization and claim submission.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) |
| Policy Code | CPB 0558 |
| Change Type | Modified |
| Effective Date | February 21, 2026 |
| Impact Level | High |
| Specialties Affected | Interventional Cardiology, Structural Heart Programs, Cardiac Surgery |
| Key Action | Audit your prior authorization packets for CPT 93583 against all seven medical necessity criteria before submitting claims on or after February 21, 2026 |
Aetna PTSMA Coverage Criteria and Medical Necessity Requirements 2026
CPB 0558 Aetna sets a high bar for PTSMA approval. Every criterion below must be satisfied — Aetna uses the word "all." Miss one, and you're looking at a claim denial.
For adults 21 and older, Aetna considers PTSMA medically necessary when these seven criteria are all met:
| # | Covered Indication |
|---|---|
| 1 | Symptom duration and failed therapy. The member has severe symptoms — dyspnea, angina, syncope or presyncope, palpitations, or heart failure — for at least six months. Those symptoms must persist despite optimal drug therapy (beta-blockers, calcium antagonists), dual-chamber pacing, or a prior surgical myotomy/myectomy that didn't work. |
| 2 | NYHA classification. The member is New York Heart Association Class III or IV. Document this explicitly in your prior authorization packet. Vague functional status notes won't support reimbursement. |
| 3 | Confirmed HOCM morphology. Echocardiography must confirm classical, asymmetric subaortic HOCM. Mid-ventricular, concealed membranous subaortic stenosis, and supravalvular forms are not covered under this criteria set. |
| 4 | Left ventricular wall thickness. Echocardiography must show LV wall thickness greater than 13 mm in adults (no other cause for LV hypertrophy present), or greater than 15 mm in athletes. |
| 5 | Systolic anterior motion (SAM). Echocardiography must confirm SAM of the mitral valve. This is a hard documentation requirement — not optional clinical context. |
| 6 | LVOT gradient thresholds. The member must meet one of these: resting LVOT gradient greater than 30 mm Hg, stressed gradient greater than 60 mm Hg, or (for less severe symptoms) resting LVOT greater than 50 mm Hg or stress LVOT greater than 100 mm Hg. |
| 7 | No prohibitive coronary artery disease. CAD must not preclude performance of the procedure. Your cardiac cath documentation needs to address this directly. |
This is a tight, seven-point checklist. The real issue here is that Aetna's medical necessity standard leaves almost no room for borderline cases. If the echo doesn't clearly show SAM, or the LVOT gradient is borderline, expect a denial.
Pediatric and adolescent coverage is more limited. Aetna considers PTSMA medically necessary for patients aged 5 to 20 only when they have failed medical therapies — specifically amiodarone, beta-blockers, and verapamil — or have contraindications to surgery. They also must meet the same adult selection criteria above. This isn't a routine coverage extension. It's a narrow, last-resort pathway.
Prior authorization is a practical requirement for CPT 93583 in any non-emergent PTSMA case. Build your auth packet around all seven criteria, and include the echocardiographic data explicitly. Submitting without echo documentation is the fastest path to denial.
Aetna PTSMA Exclusions and Non-Covered Indications
Three categories fall entirely outside Aetna's PTSMA coverage policy. Know them before you bill.
HOCM with myocardial bridge. Aetna classifies PTSMA for HOCM complicated by myocardial bridge as experimental, investigational, or unproven. No amount of documentation changes that. If the diagnosis involves myocardial bridge, CPT 93583 will not be covered.
Ultrasound-guided PTSMA. The standard alcohol-based technique is covered when criteria are met. The ultrasound-guided variant is not. Aetna considers it experimental due to insufficient safety and effectiveness evidence. This is an important distinction for structural heart programs trialing newer imaging guidance protocols — the coverage policy does not follow the technology.
SESAME procedure. The Septal Scoring Along Midline Endocardium procedure for hypertrophic cardiomyopathy is explicitly experimental and unproven under this policy. Don't bill it expecting coverage under CPB 0558.
These exclusions are final under this policy. If your team is billing any of these variants, stop now. Recode or redirect to the appropriate pathway.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| PTSMA (alcohol septal ablation) for HOCM — adults 21+, all 7 criteria met | Covered | CPT 93583, HCPCS C1886, ICD-10 I42.1 | Prior auth recommended; full echo documentation required |
| PTSMA for HOCM — ages 5–20, failed medical therapy or surgical contraindication | Covered (limited) | CPT 93583, HCPCS C1886, ICD-10 I42.1 | Must also meet adult selection criteria; narrow pathway |
| PTSMA for HOCM complicated by myocardial bridge | Experimental / Not Covered | CPT 93583 | Insufficient evidence per Aetna |
| Ultrasound-guided PTSMA for HOCM | Experimental / Not Covered | CPT 93583 | Guidance modality not covered regardless of underlying indication |
| SESAME procedure for hypertrophic cardiomyopathy | Experimental / Not Covered | — | Explicitly excluded; ICD-10 I42.1 and I42.2 may apply but procedure is non-covered |
| Other hypertrophic cardiomyopathy (non-obstructive) | Not Covered | ICD-10 I42.2 | PTSMA not indicated for non-obstructive HCM under this policy |
Aetna PTSMA Billing Guidelines and Action Items 2026
The effective date is February 21, 2026. If you're billing CPT 93583 for Aetna members, here's what to do now.
| # | Action Item |
|---|---|
| 1 | Audit your prior authorization templates against all seven criteria. Pull your current PTSMA auth packet. Compare it line by line against the seven adult medical necessity criteria in CPB 0558. If you're missing explicit documentation for any single criterion — especially the NYHA class, the LVOT gradient, and the SAM finding — update the template before February 21, 2026. |
| 2 | Flag pediatric cases separately. PTSMA for patients aged 5 to 20 has a distinct pathway. Your billing team and clinical team should coordinate on these. Build a checklist for failed medical therapies (amiodarone, beta-blockers, verapamil) and surgical contraindications. Don't use the adult template for a 17-year-old — the documentation requirements overlap but the pathway is different. |
| 3 | Remove ultrasound-guided PTSMA from any covered service lists. If your charge capture or CDM lists ultrasound-guided PTSMA as a covered Aetna service, correct that now. Aetna PTSMA billing guidelines are explicit: only the standard alcohol-based technique is eligible for coverage. The ultrasound-guided variant will deny. |
| 4 | Check your HCPCS C1886 billing against CPT 93583 encounters. HCPCS C1886 (catheter, extravascular tissue ablation) is tied to this policy. Make sure it appears on claims alongside CPT 93583 when applicable, and that the corresponding documentation supports the full procedure — not just device use. |
| 5 | Verify ICD-10 diagnosis code accuracy. Use I42.1 (obstructive hypertrophic cardiomyopathy) for covered PTSMA cases. I42.2 (other hypertrophic cardiomyopathy) should not anchor a claim for PTSMA — the procedure targets the obstructive form. A mismatch between I42.2 and CPT 93583 is a red flag for denial. |
| 6 | Train your cardiology coders on the SESAME exclusion. If your structural heart program is performing or considering the SESAME procedure, your coders need to know it is explicitly non-covered under CPB 0558. There is no workaround here under this Aetna coverage policy. |
| 7 | If you have borderline cases, talk to your compliance officer. The LVOT gradient thresholds and the "less severe symptoms" carve-out in criterion six create edge cases. If you're uncertain whether a member's clinical profile supports medical necessity, loop in your compliance officer before submitting. A denied claim in this category often becomes an overpayment audit issue on resubmission. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for PTSMA Under CPB 0558
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 93583 | CPT | Percutaneous transcatheter septal reduction therapy (e.g., alcohol septal ablation) including temporary pacemaker insertion when performed |
Supporting HCPCS Codes
| Code | Type | Description |
|---|---|---|
| C1886 | HCPCS | Catheter, extravascular tissue ablation, any modality (insertable) |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| I42.1 | Obstructive hypertrophic cardiomyopathy |
| I42.2 | Other hypertrophic cardiomyopathy |
Bill CPT 93583 with I42.1 for covered PTSMA cases. I42.2 maps to non-obstructive HCM — using it to support a PTSMA claim is a documentation mismatch that invites denial. HCPCS C1886 should accompany 93583 on facility claims when an insertable ablation catheter is used.
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