33214
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.40
Facility
$425.53
Non-Facility
$425.53
Documentation Required
- Documentation of NYHA functional class (I–IV) per Appendix.
- Documentation of sinus rhythm (explicit statement in medical record/EKG).
- Left ventricular ejection fraction (LVEF) measurement demonstrating LVEF less than or equal to 35% (echocardiogram or other imaging) when applicable to indications A/B.
- QRS duration documentation from 12-lead ECG: QRS duration greater than or equal to 150 msec (for NYHA III/IV pathway) or QRS duration thresholds as specified (>=150 ms or >=130 ms with LBBB as applicable).
Key Coverage Criteria
- - I47.1 Supraventricular tachycardia [with at least 1 episode of cardiac arrest]
- - I47.20, I47.21, I47.29 Ventricular tachycardia [with at least 1 episode of cardiac arrest or recurrent tachycardia]
- - I48.0 Atrial fibrillation (listed under combination devices as covered when member is at high risk for sudden cardiac death)
- - I24.0 - I25.2 (acute, subacute, and old myocardial infarction range listed) [noted: 'prior heart attack and episode of non-sustained VT, with an inducible ventricular tachyarrhythmia']
- - I46.2 Cardiac arrest due to underlying cardiac condition [ventricular tachyarrhythmias or LVEF less than or equal to 30%]
- Aetna considers U.S. Food and Drug Administration (FDA)-approved biventricular pacemakers (cardiac resynchronization therapy) medically necessary for the treatment of members with congestive heart failure (CHF) who are in sinus rhythm when either of the following criteria is met (A or B):
7 Active Policies
AETNA-CPB-0610 — Cardiac Resynchronization Therapy and Other Pacing/Defibrillator Treatments for Heart Failure
CARELON-cardiac-resynchronization-therapy-2024-10-20 — Cardiac Resynchronization Therapy
CARELON-permanent-implantable-pacemakers-2024-03-17 — Permanent Implantable Pacemakers
HUMANA-CARDIAC-PACEMAKERS-MA — Cardiac Pacemakers - Medicare Advantage
Related Codes
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