Cardiac Resynchronization Therapy (CRT)

This policy covers cardiac resynchronization therapy (CRT) primarily for symptomatic systolic heart failure patients with LVEF ≤ 35% who have prolonged QRS duration (with specific allowances for QRS >150 ms or 130–149 ms with LBBB), are on maximally tolerated GDMT for ≥ 3 months with no reversible causes, and meet NYHA functional class criteria. CRT is not covered for patients with LVEF > 50%, non-ambulatory NYHA IV, those on chronic inotropes, or patients with LVADs; several provisions (e.g., upgrades, AF management, COPD or renal disease) require documented individualized rationale and plans. Ambiguities in some QRS-related noncoverage language and certain EF/NYHA combinations for pacemaker-indicated patients require manual review of the source policy text.

"CRT is medically necessary for patients with LVEF ≤ 35% (ischemic or non-ischemic cardiomyopathy), on maximally tolerated guideline-directed medical therapy (GDMT) for ≥ 3 months with no reversible..."