Biventricular Pacemakers for the Treatment of Congestive Heart Failure  Printer-Friendly Version
Medical Policy: 02.02.01
Original Effective Date: May 2002
Reviewed: August 2008
Revised: April 2007
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Biventricular cardiac pacing, also known as cardiac resynchronization therapy is used to treat the cardiac ventricular dyssynchrony frequently associated with heart failure. Strategic electrical stimulation to the right atrium, right ventricle, and left ventricle, coordinates ventricular contractions (after optimal shortening of the atrioventricular delay) thereby improving cardiac output. Biventricular pacemakers may be combined with automatic implantable cardiac defibrillators. These combination devices are indicated for patients at high risk of sudden cardiac death due to ventricular arrhythmias and who also have heart failure.
Policy:
Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e. a combined biventricular pacemaker/ICD) may be considered medically necessary as a treatment of congestive heart failure in patients who meet all of the following criteria:
- NYHA class III or IV
- Left ventricular ejection fraction less than or equal to 35%
- QRS duration greater than or equal to 120 msec
- A stable pharmaceutical regimen established prior to implant
An intrathoracic fluid monitoring sensor is considered investigational as a component of a biventricular pacemaker.
Biventricular pacemakers with or without an accompanying implantable cardiac defibrillator are considered investigational in patients not meeting the above criteria.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT 33224, Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion and/or replacement of generator)
- CPT 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system)
- CPT 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
- CPT 33241 Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator
- CPT 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
- CPT 33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure)
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Selected References:
- A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- Bradley DJ et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized controlled trials. JAMA 2003;289(6):730-740.
- Abraham WT. Et al. Cardiac resynchronization in chronic heart failure. New England Journal of Medicine 2002;346(24):1845-1853.
- Del Negro A. Cardiac resynchronization therapy: concerns, mechanisms and alternatives. Medscape Cardiology 2002;6(2).
- ECRI. Biventricular Pacing Systems (Cardiac Resynchronization Therapy) for Heart Failure. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2002 Aug. (Windows on medical technology; no 81).
- Kass DA Ventricular resynchronization: Pathophysiology and identification of responders. Rev Cardiovasc Med. 2003;4 Suppl 2:S3-S13.
- Kass DA Predicting cardiac resynchronization response by QRS duration. J Am Coll Cardiol. 2003 Dec 17;42(12):2125-2127.
- Bristow MR, Saxon LA, Boehmer J et al. Cardiac resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350(21):2140-50.
- Linde C, Leclercq C, Rex S et al. Long-term benefits of biventricular pacing in congestive heart failure: results from the Multisite Stimulation in Cardiomyopathy (MUSTIC) study. J Am Coll Cardiol 2002; 40(1):111-8.
- Young JB et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD trial. JAMA 2003 May 28;289(20):2719-21.
- Philippon F. Cardiac resynchronization Therapy: Device-Based Medicine for Heart Failure. Journal of Cardiac Surgery. 2004 May-June; 19(3):270-74.
- Tada H, Toide H, Naito S et al. Tissue Doppler imaging and strain Doppler imaging as modalities for predicting clinical improvement in patients receiving biventricular pacing. Circ. J. 2005 Feb;69(2):194-200.
- Blue Cross Blue Shield Association. Biventricular Pacemakers for the Treatment of Congestive Heart Failure. Medical Policy Reference Manual (MPRM);2005.
- Dzemali O, Bakhtiary F, Dogan S et al. Perioperative biventricular pacing leads to improvement of hemodynamics in patients with reduced left-ventricular function-interim results. Pacing Clin Electrophysiol. 2006 Dec;29(12):1341-5.
- Epstein AE, DiMarco JP, Ellenbogen KA et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008 May 27;51(21):e1-62.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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