33228
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.38
Facility
$315.30
Non-Facility
$315.30
Documentation Required
- Documented diagnosis of nonischemic dilated cardiomyopathy.
- Imaging documentation for HCM: 2D echocardiography or cardiovascular magnetic resonance (CMR) showing maximal end-diastolic wall thickness ≥ 15 mm (or 13-14 mm with supporting evidence as described)
- When wall thickness is 13-14 mm, documentation of family history of HCM, positive genetic test, typical dynamic outflow obstruction, or distinctly abnormal ECG patterns to support diagnosis
- For Class IV heart failure: documentation that heart failure is ambulatory, absence of active acute coronary syndrome, documentation of no inotrope use, and evidence patient is on guideline-directed medical therapy (GDMT)
Key Coverage Criteria
- Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads | 33231
- LV ejection fraction ≤ 35% despite ≥ 3 months of optimal medical therapy (OMT)
- Left bundle branch block with QRS ≥ 120 msec
- Symptomatic heart failure NYHA functional Class II, III, or ambulatory class IV
- Sinus rhythm (section heading: 'Sinus rhythm, dilated cardiomyopathy with LBBB (CRID-5.1)')
- class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
6 Active Policies
CARELON-permanent-implantable-pacemakers-2024-03-17 — Permanent Implantable Pacemakers
HUMANA-CARDIAC-PACEMAKERS-MA — Cardiac Pacemakers - Medicare Advantage
EVICORE-CARDIOVASCULAR_RADIOLOGY-1D1A3C37 — Addendum to the eviCore Imaging Guidelines
EVICORE-CRID_FINAL — Cardiac Rhythm Implantable Devices (CRID) Guidelines
Related Codes
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