0409T — Insj/rplc car modulj pls gn
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Evidence of enrollment in an approved clinical research study or trial (preferably randomized controlled trial) or institutional review board–approved protocol.
- Protocol documentation including patient selection criteria and study design.
- Detailed records of stimulation parameters: duration, timing, and planned duration of effect monitoring.
- Baseline and follow-up outcome measures including ejection fraction (EF), oxygen consumption (VO2), New York Heart Association (NYHA) classification, and patient-reported outcomes including quality of life (QOL).
Key Coverage Criteria
- Use of diagnostic tests (blood tests, electrocardiogram, chest x‑ray, stress test, echocardiogram) to aid in diagnosing heart failure.
- Echocardiogram (ECG/echo) to evaluate cardiac structure and function and to measure ejection fraction (EF); EF >50% is normal, EF <40% is consistent with systolic heart failure; heart failure may also occur with normal EF due to diastolic dysfunction (stiff myocardium).
- Medical treatment of heart failure to stop or delay disease progression, manage symptoms, prevent organ damage, reduce hospitalizations, and prolong life.
- Use of guideline-directed pharmacologic therapy for heart failure including angiotensin receptor neprilysin inhibitors (ARNI), ACE inhibitors, angiotensin II receptor blockers (ARBs), beta blockers, diuretics, aldosterone antagonists, inotropes, and digoxin as clinically indicated.
- Surgical interventions for heart failure when clinically indicated, including coronary artery bypass grafting (CABG), heart valve repair or replacement, and heart transplantation.
- Use of implantable cardiac devices for heart failure when clinically indicated, including pacemakers, implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT)/biventricular pacing, and ventricular assist devices (VADs).
5 Active Policies
BCBSIL-MED202.068 — Cardiac Contractility Modulation (CCM) Device
BCBSMT-MED202.068 — Cardiac Contractility Modulation (CCM) Device
BCBSNM-MED202.068 — Cardiac Contractility Modulation (CCM) Device
BCBSOK-MED202.068 — Cardiac Contractility Modulation (CCM) Device
MED202.068 — Cardiac Contractility Modulation (CCM) Device
Related Codes
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