IVUS, OCT Still Struggling for Traction in Cath Labs
(Posted Sept. 3, 2026, on LinkedIn)
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are anything but the latest thing in the modern cath lab, but cardiologists seem less than unified in their views of their utility. At one end of the debate is a recommendation for extensive use of these modalities for high-risk patients undergoing angioplasty and stenting while on the other is a recent study casting doubt on whether IVUS and OCT improve outcomes in some of these high-risk patients.
These two leading modalities for intracoronary imaging emerged at markedly different times, with IVUS reputedly coming into being in the 1980s. The history of OCT spans more than two decades and was the subject of investigational studies at least as far back as 2002. LightLab Imaging began enrollment of a clinical study for its OCT imaging system that year, and as if to demonstrate industrial confidence in OCT, LightLab went on to become part of St. Jude Medical in 2010. St. Jude was in turn acquired by Santa Clara, Calif.-based Abbott Vascular several years later.
Doc societies bullish on both IVUS, OCT
In February 2025, several medical specialty societies issued an updated version of guidelines for management of patients presenting with acute coronary syndrome (ACS). The guidelines call for the use of IVUS or OCT for patients undergoing stent implant in the left main coronary artery and for patients presenting with complex lesions, apparently within and outside of the left main. The authors cited studies suggesting that either modality can aid in proper stent placement and expansion, which in turn help reduce episodes of dissection.
The authors of the guidelines highlighted some of the contrasting capabilities of IVUS and OCT, such as that the former provides exceptional insights into the extent of calcification and plaque burden. In contrast, OCT provides more information about the thickness of calcification and the likelihood of plaque rupture, but both IVUS and OCT are credited with “play[ing] essential roles in evaluating the necessity for lesion preparation” as well as stent selection for size. Ultimately, the use of intravascular imaging is in general deemed helpful for confirming proper stent expansion and reducing the likelihood of complications.
However, clinicians are not universally persuaded of the utility of intraoperative intravascular imaging. A study published recently in the New England Journal of Medicine suggests that IVUS offers little benefit to patients undergoing PCI. Roughly 27% of the enrollees in this study were diagnosed with ACS, and the authors led with the observation that patients with complex lesions are presumed to fare better when IVUS is deployed during the procedure.
This paper, appearing March 30, 2026, in NEJM, describes a study conducted primarily or entirely in Europe and which enrolled 2,020 patients evenly between IVUS and non-IVUS (conventional angiography) procedures. The mean age is pertinent to the U.S. Medicare population (69 years), although the study population is heavily tilted toward men at 79.4%.
As one might expect, procedural complications were slightly higher in the IVUS group at 11.3% versus 10.2% in the angiography group, but target-vessel failure was also higher in the IVUS group (13.9% versus 11.1%). Procedure time was significantly higher with IVUS (88.8 minutes versus 66.2 minutes for angiography), a metric that drives per-procedure cost and which may reduce an institution’s overall procedure volumes.
Lack of NCD leaves providers with a Medicare thicket
There are significant differences between IVUS and OCT where Medicare coverage, coding and payment are concerned, but neither modality is the subject of a national coverage determination. This leaves utilization susceptible to the vagaries of Medicare administrative contractor (MAC) coverage policies. An example of this is a local coverage determination (L34761) issued by Wisconsin Physician Services (WPS) in 2015 and updated in 2025 for technical edits. This policy offers separate coverage for IVUS during percutaneous interventions assuming angiography returns equivocal results for stenosis. This policy does not mention OCT, but states that IVUS may be performed on multiple vessels during a PCI procedure.
Several coding considerations are at play when IVUS and/or OCT are invoked for PCI procedures. In one of the more recent developments, Noridian Healthcare Solutions added HCPCS code C7569 to its covered procedures for calendar year 2026. Noridian describes this code as offering coverage of either IVUS or OCT for a single major coronary artery or a branch thereof during diagnostic evaluation and/or therapeutic intervention. This policy covers imaging supervision of PCI as well as interpretation and report of the findings.
By some accounts, HCPCS C7569 is allowable on claims for procedures performed in an ambulatory surgical center (ASC) as well as those conducted in hospital outpatient department procedures. This code can be used in Medicare Part A claims as well, according to CMS, indicating that this HCPCS C7569 is allowable for inpatient procedures.
The problem with C7569 is that it is a temporary level II C code and thus its permanence cannot be taken for granted. One manufacturer lists the facility reimbursement at a bit more than $6,500 when deployed during outpatient procedures performed in an ASC.
While private payers are generally believed to lag somewhat behind Medicare coverage policies, this is not universally the case. Aetna of Hartford, Conn., covers OCT for patients presenting with ACS as of April 2026. This is limited to stent implant in the left main or in complex lesions, but Aetna’s approach to IVUS is broader and more generous.
As of May 2026, Aetna covers IVUS as a clinical decision-making tool for patients who may need intracoronary intervention when angiography demonstrates a rate of stenosis of 50-70%. IVUS is also covered for guidance of device placement for stenting, angioplasty and atherectomy for the coronary arteries under this policy. However, the payer is at present wary of the use of IVUS for virtual histology (analysis/depiction of plaque composition) due to a lack of evidence of clinical utility.
