33274
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.61
Facility
$419.52
Non-Facility
$419.52
Documentation Required
- Claims for Group I and Group II diagnoses must be attested with modifier KX to confirm documentation is on file verifying symptomatic arrhythmia or high risk of progression requiring a permanent pacemaker.
- Group II contractor‑allowed diagnoses must be accompanied by the applicable ICD‑10‑CM diagnosis code(s) on the claim and KX attestation; contractor determination may be required for coverage.
- Group III conditions (not addressed by the NCD) should be attested with modifier SC when applicable and are subject to separate contractor review and coverage policies.
- Only CPT codes for initial insertion of permanent pacemakers (33206, 33207, 33208) apply to this NCD; claims should use these CPTs for initial implant procedures and not replacement CPTs addressed elsewhere.
Key Coverage Criteria
- Implantation of a single‑chamber or dual‑chamber permanent cardiac pacemaker is covered for documented non‑reversible symptomatic bradycardia due to sinus node dysfunction.
- Implantation of a single‑chamber or dual‑chamber permanent cardiac pacemaker is covered for documented non‑reversible symptomatic bradycardia due to second‑degree and/or third‑degree atrioventricular (AV) block.
- Symptoms attributable to bradycardia (heart rate <60 bpm) such as syncope, seizures, congestive heart failure, dizziness, or confusion qualify as symptomatic bradycardia for coverage purposes.
- Additional contractor‑allowed diagnoses (Group II) are covered when the practitioner attests (use modifier KX) that documentation is on file verifying symptomatic arrhythmia or high potential for progression; examples include symptomatic/selected bundle branch/fascicular blocks, certain supraventricular tachycardias when pacing controls SVT, atrial fibrillation/flutter with symptomatic bradycardia due to therapy, and hypersensitive carotid sinus syndrome with cardioinhibitory response.
- Leadless pacemaker procedures (initial placement or replacement) are covered only when performed in CMS-approved Coverage with Evidence Development (CED) clinical studies per NCD 20.8.4 effective January 18, 2017.
- Coverage under this NCD applies to both Medicare Part A and Part B claims when the CED conditions are met.
6 Active Policies
A54831 — Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker
A59819 — Billing and Coding: Leadless Pacemakers
CARELON-permanent-implantable-pacemakers-2024-03-17 — Permanent Implantable Pacemakers
HUMANA-CARDIAC-PACEMAKERS-MA — Cardiac Pacemakers - Medicare Advantage
EVICORE-CRID_FINAL — Cardiac Rhythm Implantable Devices (CRID) Guidelines
Related Codes
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