33990
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.58
Facility
$312.97
Non-Facility
$312.97
Documentation Required
- Medical record documentation must support the specific diagnosis corresponding to one of the listed ICD-10-CM codes and explicitly state that IABP is not expected to be sufficient.
- Clinical documentation should indicate the life-threatening nature (e.g., cardiogenic shock, multi-organ failure, or intra/postoperative circulatory collapse) and any supporting hemodynamic or organ-failure data.
- Medical record must document diagnosis supporting one of the three life‑threatening situations and cite the relevant ICD‑10‑CM code(s).
- Medical record must document that external counterpulsation (IABP) is not expected to be sufficient for the patient.
Key Coverage Criteria
- Percutaneous endovascular cardiac assist device is covered for cardiogenic shock (ICD-10-CM R57.0) when intraaortic balloon pump (IABP) is not expected to be sufficient.
- Percutaneous endovascular cardiac assist device is covered for severe decompensated heart failure with threatening multi-organ failure when documented by one of the ICD-10-CM codes I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, or I97.131 and when IABP is not expected to be sufficient.
- Percutaneous endovascular cardiac assist device is covered for intraoperative or postoperative circulatory system complications/disturbances documented by ICD-10-CM codes I97.790, I97.791, I97.88, or I97.89 when IABP is not expected to be sufficient.
- Percutaneous endovascular cardiac assist device is covered for cardiogenic shock when external counterpulsation (IABP) is not expected to be sufficient.
- Percutaneous endovascular cardiac assist device is covered for severe decompensated heart failure with threatening multi-organ failure when external counterpulsation (IABP) is not expected to be sufficient.
- Percutaneous endovascular cardiac assist device is covered for intraoperative or postoperative complications/disturbances of the circulatory system when external counterpulsation (IABP) is not expected to be sufficient.
6 Active Policies
AMBETTER-CP.MP.46 — Ventricular Assist Devices
A53986 — Billing and Coding: Percutaneous Ventricular Assist Device
A53988 — Billing and Coding: Percutaneous Ventricular Assist Device
A59657 — Billing and Coding: Artificial Hearts and Percutaneous Endovascular Cardiac Assist Procedures and Devices
HUMANA-VENTRICULAR-ASSIST-DEVICE-TOTAL-ARTIFICIAL-HEART-MA — Ventricular Assist Device, Total Artificial Heart - Medicare Advantage
Related Codes
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