36013
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.46
Facility
$112.23
Non-Facility
$775.23
Documentation Required
- Use of the most appropriate CPT/HCPCS codes for the service as of the date of service; claims must be accompanied by the covered code(s) to be considered for reimbursement.
- Clinical documentation that would be relevant when evaluating these technologies (as implied in the policy background and device indications) and that should be available in the medical record if coverage is being considered or appealed: - NYHA functional class documentation (I–IV) recorded by clinician. - Left ventricular ejection fraction (LVEF) with date and imaging modality (e.g., echocardiogram) and value (percent). - Natriuretic peptide levels (BNP or NT-proBNP) with dates and values (policy cites NT-proBNP thresholds used in trials, e.g., <1600 pg/mL vs >1600 pg/mL). - History of heart failure hospitalization(s) (dates, setting) within the prior 12 months, or documentation of elevated natriuretic peptides if no recent hospitalization. - Documentation of guideline-directed medical therapy (GDMT) status and duration (stable on GDMT and for how long — e.g., 30 days, 3 months, etc., as referenced for device trials and device labeling). - Documentation regarding CRT candidacy/status (e.g., whether patient is indicated for cardiac resynchronization therapy), when relevant. - For carotid sinus baroreflex activation: pre-implant carotid imaging (ultrasound or angiography) documenting carotid bifurcation location, percent atherosclerosis, presence/absence of ulcerative plaques. - Allergy history relevant to device materials (e.g., silicone, titanium) for BAROSTIM. - For pulmonary artery and other implantable pressure sensors: documentation of right heart catheterization data when performed (used for implantation/calibration in trials), and any device calibration records. - For devices with anticoagulation requirements (e.g., Cordella): documentation of ability to take dual antiplatelet therapy or anticoagulation for the required post-implant period (e.g., 1 month). - For inferior vena cava sensor (Norm/FIRE1) early studies: CT or imaging that documents IVC dimensions if used to correlate sensor measurements, and documentation of prior HF decompensation events per trial inclusion criteria. - Any procedural notes, device implantation reports, and records of device- or procedure-related complications should be available.
Key Coverage Criteria
- No covered indications. The following device implantations and monitoring procedures are considered experimental, investigational or unproven and are NOT covered under this policy: carotid sinus baroreflex activation device (e.g., BAROSTIM NEO) (CPT 0266T, 0268T; HCPCS C1825), left atrial pressure sensor implantation and monitoring (CPT 0933T), pulmonary artery pressure sensor implantation and monitoring (CPT 33289; HCPCS C2624, G0555), cardiac contractility modulation therapy (OPTIMIZER Smart S [...]
- No covered indications. The policy's Coverage Policy section states the following are "considered experimental, investigational or unproven": "Carotid sinus baroreflex activation device (CPT® 0266T, 0268T and HCPCS code C1825)", "Implantation and monitoring of a left atrial pressure sensor (CPT® 0933T)", "Implantation and monitoring of a pulmonary artery pressure sensor (CPT® 33289 and HCPCS C2624, G0555)", "The use of cardiac contractility modulation therapy (CPT® 0408T, 0915T-0918T, 0930T-0931 [...]
- Added new policy statement for inferior vena cava sensor
- Added new policy statement for left atrial pressure sensor
- Added new policy statement for carotid sinus baroreflex activation device (i.e., BAROSTIM NEO System)
- Revised policy statement for carotid sinus baroreflex activation device
2 Active Policies
CIGNA-0574 — Cardiac Omnibus Codes - (0574)
CIGNA-0574-FUTURE — Cardiac Omnibus Codes - (0574)
Related Codes
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