Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

This policy covers biventricular pacemakers (cardiac resynchronization therapy, with or without an ICD) to coordinate ventricular contraction and improve hemodynamics in patients with heart failure. Covered populations include symptomatic HFrEF patients (typically NYHA class III–IV) with LVEF ≤35% in sinus rhythm on guideline‑directed medical therapy including the policy‑required medication classes; selected NYHA I–II patients with LVEF ≤30% and left bundle branch block or QRS ≥150 ms, and patients with AV block expected to require a high percentage of ventricular pacing (LVEF ≤50%) as an alternative to right‑ventricular pacing. Coverage is limited to individuals who meet all specified criteria (NYHA class, LVEF, rhythm, optimized therapy, and QRS/AV‑block parameters) and excludes use of non–FDA‑approved or investigational approaches (e.g., triventricular pacing, wireless LV endocardial pacing, intrathoracic sensors).

"Biventricular pacemaker (with or without ICD) is medically necessary for treatment of heart failure in patients with NYHA class III or IV heart failure who meet ALL of the following: LVEF ≤35%, are..."