C2621, Pacemaker, other than single or dual chamber (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation: Providers may be required to submit clinical documentation in support of a request for services.
- Documentation: Such documentation must accurately reflect the clinical situation at the time of the requested service, and sufficiently document the ordering provider’s clinical intent.
Key Coverage Criteria
- Indication: Permanent pacemaker placement is medically necessary for documented sinus node dysfunction when the patient takes no medications which would cause sinus node dysfunction (or withholding/dose reduction of such medications would be contraindicated) and any of the following apply: symptomatic arrhythmias with sinus node dysfunction when symptoms are clearly attributable to the arrhythmia; symptomatic chronotropic incompetence; symptomatic tachy-brady syndrome when the symptoms are clear [...]
- Indication: Permanent pacemaker placement is medically necessary for documented AV block when reversible causes of AV block are absent, the patient takes no medications which would cause AV node dysfunction (or withholding such medications would be contraindicated), and any of the following apply: acquired third-degree AV block (symptomatic or asymptomatic); acquired high grade second-degree block (symptomatic or asymptomatic); acquired Mobitz type II second-degree AV block (symptomatic or asymp [...]
- Indication: A single chamber leadless pacemaker (right ventricular) is medically necessary when the patient has a pacemaker indication and a leaded transvenous pacemaker cannot be placed because of venous access issues, prior infection risk, prosthetic tricuspid valve, or device replacement.
- Indication: Device replacement is medically necessary when device interrogation indicates that the device is nearing end of life (elective replacement indicator).
1 Active Policy
CARELON-permanent-implantable-pacemakers-2024-10-20, Permanent Implantable Pacemakers
Related Codes
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