Medical Policy: 01.01.28 

Original Effective Date: December 2015 

Reviewed: November 2017 

Revised: November 2017 

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

The leadless cardiac pacemaker (Nanostim Inc., Sunnyvale, Calif.) is an entirely self-contained intra-cardiac device with a screw-in active fixation mechanism. After placing an 18F sheath in the femoral vein, the device is delivered to the right ventricle using a deflectable delivery catheter with an extendable sleeve to protect the fixation helix. Once positioned, the sleeve is retracted and the device is undocked from the delivery catheter while maintaining a tethered connection to permit device measurements and assess stability. If the position is suboptimal, the leadless pacemaker can be re-engaged, unscrewed and repositioned.

 

Unlike a standard pacemaker, a leadless pacemaker does not require creation of a surgical pocket for the pacemaker, and it requires no leads. Advantages of a leadless pacemaker over a standard pacemaker is avoidance of a surgical scar or lump under the skin where the pacemaker sits. The pacemaker battery life is equivalent to that of similar standard single chamber pacemakers. Additional potential advantages include avoidance of problems with lead placement and reduction in risk of infections.

 

The Nanostim leadless cardiac pacemaker met pre-specified pacing and sensing requirements in the large majority of patients. Device-related serious adverse events occurred in approximately 1 in 15 patients. (Funded by St. Jude Medical; LEADLESS II ClinicalTrials.gov number, NCT02030418.)

 

The Micra (Medtronic) leadless pacemaker is similar in concept to the Nanostim leadless cardiac pacemaker (St Jude Medical), another device that is further ahead in testing. The two pacemakers differ slightly in terms of how they are lodged into the myocardium of the RV apex, however.

 

Another concept in leadless pacing is a multi-component ultrasound-based LV endocardial pacing system for cardiac resynchronization therapy: the WiCS system (Wireless Cardiac Stimulation, EBR systems, Sunnyvale, CA, USA).

 

Prior Approval:

 

Not applicable

 

Policy:

Leadless Cardiac pacemakers including, but not limited to the Nanostim and Micra devices, are considered investigational.

 

The short performance of leadless cardiac pacemakers is available, the intermediate and long-term performance of these devices requires significantly more published data. The unknown long term outcomes, coupled with the adverse event concerns during clinical trials indicate there is insufficient evidence on long term effectiveness and overall net health outcomes.  Additional studies are necessary to evaluate the safety, efficacy and stability of leadless pacemakers. Removal of the device and complications are currently unknown.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 0387T  Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular
  • 0388T  Transcatheter removal of permanent leadless pacemaker, ventricular
  • 0389T  Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system
  • 0390T  Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system
  • 0391T  Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

 

Selected References:

  • Leadless Pacemaker
  • Reddy VY, Knops RE, Sperzel J, et al. Permanent leadless cardiac pacing: Results of the LEADLESS trial. Circulation. 2014;129(14):1466-1471.
  • Nanostim™ Leadless Pacemaker.
  • O'Riordan M. First-in-human data shows Medtronic's leadless pacemaker safe out to 90 days. Medscape Medical News, June 19, 2014.
  • Ritter P, Duray G, et al. Early performance of a 2inaturized leadless cardiac pacemaker: the Micra transcatheter pacing study. Eur Heart J. 2015 Oct 1; 36(37): 2510–2519.
  • Higgins SL, Rogers JD. Advances in pacing therapy: examining the potential impact of leadless pacing therapy. The Journal of Innovations in Cardiac Rhythm Management, 5 (2014): 1825–1833.
  • ECRI Institute. Good pacing, sensing results reported for leadless cardiac pacemaker. Technology Forecast Report, August 28, 2015.
  • Knops RE, Tjong FV, Neuzil P, et al. Chronic performance of a leadless cardiac pacemaker: 1-year follow-up of the LEADLESS trial. J Am Coll Cardiol 2015;65:1497-504. –
  • Miller MA, Neuzil P, Dukkipati SR, Reddy VY. Leadless Cardiac Pacemakers: Back to the Future. J Am Coll Cardiol 2015;66:1179-89.
  • Sperzel J, Burri H, Gras D, et al. State of the art of leadless pacing. Europace. 2015 May 29 [Epub ahead of print].
  • Link M.S. Achilles' lead: will pacemakers break free? N Engl J Med. 2016 Feb 11;374(6):585–586.
  • Reynolds D., Duray G.Z., Omar R. A leadless intracardiac transcatheter pacing system. N Engl J Med. 2016;374:533–541.
  • Gopi, A. Leadless cardiac pacing.  Indian Pacing Electrophysiol J. 2016 Mar-Apr; 16(2): 80–81. Published online 2016 Aug 26.  doi:  10.1016/j.ipej.2016.08.009
  • ECRI Health Technology Forecast. Updated 4/4/2017

  • U.S Food and Drug Administration (FDA). FDA executive summary memorandum. General issues: leadless pacemaker devices. Silver Spring (MD): U.S Food and Drug Administration (FDA); 2016 Feb 18. 12 p.

  • Duray GZ, Ritter P, El-Chami M, Narasimhan C, Omar R, Tolosana JM, Zhang S, Soejima K, Steinwender C, Rapallini L, Cicic A, Fagan DH, Liu S, Reynolds D, Micra Transcatheter Pacing Study Group. Long-term performance of a transcatheter pacing system: 12-Month results from the Micra Transcatheter Pacing Study. Heart Rhythm. 2017 Feb 10

  • Vamos M, Erath JW, Benz AP, Bari Z, Duray GZ, Hohnloser SH. Incidence of cardiac perforation with conventional and with leadless pacemaker systems: a systematic review and meta-analysis. J Cardiovasc Electrophysiol. 2017 Mar;28(3):336-46.

 

Policy History:

  • November 2017 - Annual Review, Policy Revised
  • November 2016 - Annual Review, Policy Revised
  • December 2015 - New medical policy

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.