Anthem Blue Cross Connecticut CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure Form

This document addresses biventricular cardiac pacing to deliver cardiac resynchronization therapy (CRT) to alleviate the symptoms of moderate to severe congestive heart failure associated with left ventricular dyssynchrony. It also addresses a hybrid device that combines CRT with an implantable cardioverter defibrillator (ICD). In the combined device (CRT/ICD), the CRT component promotes coordinated contraction of both ventricles, while the ICD portion detects dangerous arrhythmias and shocks the heart back into a normal rhythm. Biventricular pacemakers, also known as CRT devices, have three leads – one connected to the right atrium, one to the left ventricle, and one to the right ventricle. In contrast, dual-chamber pacemakers have two leads, one connected to the right atrium and the right ventricle. This document does not address wireless CRT.

Note: For further information, see:

• CG-SURG-97 Cardioverter Defibrillators
• SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

Clinical Indications

Medically Necessary:

Biventricular pacemakers for cardiac resynchronization therapy (CRT) are considered medically necessary for individuals who meet all of the following criteria:

1. NYHA functional Class II, III, or ambulatory Class IV symptoms* secondary to heart failure who remain symptomatic despite recommended, Guideline-directed medical therapy (GDMT) (which may include use of medications from the following drug classes, either individually or in combination for at least 3 months, unless contraindicated: renin-angiotensin system inhibition with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin [II] receptor blockers; beta blockers; mineralocorticoid receptor antagonists; and sodium-glucose cotransporter-2 inhibitors, when appropriate); and
2. Have either:
   1. Left bundle branch block (LBBB) morphology and QRS duration of 120 to 149 ms; or
   2. Any QRS morphology and QRS duration greater than or equal to 150 ms; and
3. Left ventricular ejection fraction (LVEF) less than or equal to 35%; and
4. In either:
   1. Sinus rhythm; or
   2. Atrial fibrillation when AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing.

*See Definition section for further information on New York Heart Association (NYHA) functional class.
**See Definition section for additional information about recommended drug classes.

The use of an ICD, in combination with cardiac resynchronization therapy (CRT/ICD), is considered medically necessary when the criteria listed above for CRT therapy AND the criteria within CG-SURG-97 Cardioverter Defibrillators are met.

Not Medically Necessary:

Biventricular pacemakers CRT, or combined biventricular pacemaker-defibrillator devices (CRT/ICD), are considered not medically necessary when the above criteria are not met and for all other indications.