Humana Cardioverter Defibrillators/Cardiac Resynchronization Therapy Form

Description

Implantable DevicesImplantable Devices The implantable (transvenous) cardioverter defibrillator (ICD) is an electronic device that continuously monitors heart rhythm and delivers therapy in response to a ventricular tachyarrhythmia that meets preprogrammed detection rates and duration in an individual who is at high risk of sudden cardiac death (SCD). If the heart develops a sudden life-threatening fast rhythm, the device will either deliver rapid electrical pacing pulses to terminate the arrhythmia or deliver a shock to the inside of the heart to stop the abnormal rhythm. Certain devices will also pace the heart when it beats too slowly. The devices are generally implanted in the subcutaneous tissue with one or more electrodes attached to the heart.

Following Description

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implantation, an external interrogation (evaluation) may be performed periodically to ensure the defibrillator is working correctly.

An ICD may be indicated for use in an individual at risk for SCD due to hypertrophic cardiomyopathy (HCM)

a condition in which the heart muscle thickens, making it more difficult to pump blood. Risk factors for SCD include, but may not be limited to one or more of the following:

• Personal history of cardiac arrest or sustained (greater than 30 seconds or associated with hemodynamic compromise) ventricular arrhythmias; OR
• Personal history of syncope suspected by clinical history to be arrhythmic; OR
• Family history in first- or second-degree relative of premature HCM-related sudden death, cardiac arrest or sustained ventricular arrhythmias; OR
• Cardiac imaging (echocardiography or coronary magnetic resonance [CMR]) determines maximal left ventricular (LV) wall thickness in all segments of the LV chamber, decreased ejection fraction (EF) or LV apical aneurysm; OR
• Diffuse and extensive late gadolinium enhancement (LGE), representing fibrosis, either quantified or estimated by visual inspection, comprising greater than 15% of LV mass11; OR
• Nonsustained (greater than or equal to 3 premature ventricular complexes terminating spontaneously) ventricular tachycardia (NSVT) episodes on continuous ambulatory electrocardiographic monitoring15

Cardiac resynchronization therapy (CRT)

(also known as biventricular pacing) is utilized for the treatment of some cases of advanced heart failure (HF). The CRT device provides electrical stimulation to both sides (left and right) of the heart thereby resynchronizing (coordinating) ventricular contractions. A third lead in the right atrium may also allow for synchronizing atrioventricular (AV) contractions. The device can be utilized with a defibrillator as a cardiac resynchronization therapy/implantable cardioverter defibrillator (CRT-D) or alone (without a defibrillator).

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Ventricular dyssynchrony

(uncoordinated contractions of the left and right ventricles) increases the risk for developing life-threatening arrhythmias.

Implantation of a CRT-D allows for both coordinating ventricular contractions and terminating life-threatening arrhythmias.

His bundle pacing (HBP) has been proposed as an alternative to traditional CRT therapy and involves placement of a single lead into the right atrium in the area of the His node. The bundle of His is a band of cardiac muscle fibers that transmits signals from the AV node via the bundle branches and eventually to the ventricles of the heart. The electrical conduction causes the contraction of the ventricles at a paced interval (regulated heartbeat). Left bundle branch pacing (LBBP) is another emerging technique that has a physiological pacing effect similar to HBP using lead placement in the septum of the right ventricle. (Refer to Coverage Limitations section)

The WiSE wireless cardiac resynchronization therapy system is a cardiac stimulator for left ventricular pacing used with a conventional pacemaker and/or defibrillator. It is purported to eliminate the need for a left ventricular pacing wire in the coronary sinus. (Refer to Coverage Limitations section)

Hemodynamic (fluid status) monitoring is a feature of certain CRT-Ds that provides continuous monitoring of an individual’s fluid status and is reported to aid in heart failure management. A pressure sensor lead(s) is inserted at the time of the CRT-D implantation and is purported to provide an early indicator of heart failure. An example is the OptiVol 2.0 Fluid Status Monitor, a feature available on some CRT-Ds. (Refer to Coverage Limitations section)

Subcutaneous ICDs (S-ICD) are considered less invasive than transvenous ICDs as there are no leads placed in the heart or vasculature. Instead, an electrode is placed just beneath the skin of the chest which allows sensing of cardiac rhythms and delivery of shocks if necessary. The defibrillator can sense ventricular tachycardia (VT)/ventricular fibrillation (VF) but cannot provide prolonged antibradycardia and antitachycardia pacing.

The extravascular ICD (EV-ICD), also known as a substernal ICD, is another type of device in development which performs pacing and defibrillation functions using an implantable substernal electrode. This novel ICD is reported to treat ventricular tachyarrhythmias while avoiding certain risks of transvenous ICDs because the lead is placed under the sternum (breastbone) outside the heart using a minimally invasive approach. (Refer to Coverage Limitations section)

Antibacterial envelopes (eg, Tyrx) are used to reduce the risk of infection after cardiac devices have been implanted. Prior to implantation, defibrillators or pacemakers can be placed in a bioabsorbable mesh envelope or pocket that elutes rifampin and minocycline to the surgical site for at least seven days. (Refer to Coverage Limitations section)

For information regarding antibacterial envelopes for ventricular assist device placement, please refer to Ventricular Assist Device, Total Artificial Heart Medical Coverage Policy.

Cardiac contractility modulation (CCM) is proposed to treat a symptomatic individual with HF who does not meet the criteria for CRT (eg, normal QRS duration). A pacemaker-sized device with electrodes is implanted into the chest of the individual which delivers electric pulses at regular intervals to modulate (adjust) the contractile strength of the heart muscle. Optimizer Smart is an example of a CCM device.

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(Refer to Coverage Limitations section) External Devices Wearable cardioverter defibrillators (WCD) are vest-like devices that are worn under the clothing 24 hours a day except when bathing or showering. The device monitors and treats abnormal ventricular rhythms in an individual at risk of dying from sudden cardiac arrest (SCA). It consists of a garment with an electrode belt assembly that is worn around the chest next to the skin. This belt is connected to a monitor and alarm, which are worn around the waist. If a life-threatening rhythm is detected, an electric shock is delivered to restore normal rhythm. The ASSURE System and ZOLL LifeVest are examples of WCDs.

Automated external defibrillators (AEDs) are portable electronic devices that allow a minimally trained individual to provide electric shock to prevent death due to sudden cardiac arrest. These devices monitor heart rhythm and can, if needed, deliver an electric shock to the chest wall much like a traditional (paddle) defibrillator in a hospital. (Refer to Coverage Limitations section)

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Body surface activation mapping (BSAM) is an electrocardiographic (ECG) technique that uses multiple leads to create a model that integrates cardiac anatomy, myocardial substrate and epicardial activation. BSAM is purported to improve diagnostic accuracy of acute coronary syndromes and conduction disorders as compared to the standard 12-lead ECG. This is reported to optimize cardioverter-defibrillator synchrony and resynchronization. (Refer to Coverage Limitations section)

Coverage Determination

Any state mandates for cardioverter defibrillators and/or cardiac resynchronization therapy take precedence over this medical coverage policy.

IMPLANTABLE CARDIOVERTER DEFIBRILLATORS

Primary Prevention of Sudden Cardiac Death

Humana members may be eligible under the Plan for an FDA-approved ICD for primary prevention of SCD when ALL of the following criteria are met:

• EFs must be measured by angiography, cardiac MRI, echocardiography or radionuclide scanning (waiting periods required)*; AND
• Myocardial infarctions (MIs) must be documented (if applicable) and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction; AND
• Absence of ALL of the following:
  • Any disease (eg, cancer, uremia, liver failure), other than cardiac, that is associated with a likelihood of survival less than 1 year; AND
  • Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; AND
  • Clinical symptoms or findings that would make the individual a candidate for coronary revascularization;

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AND ANY of the following indications:

• Documented conditions with a high risk of life-threatening VT, such as Brugada syndrome, cardiac sarcoidosis, catecholaminergic polymorphic VT, Chagas disease, giant cell myocarditis, HCM (with risk factors for SCD events)15, long QT syndrome (LQTS), right ventricular dysplasia or short QT syndrome (SQTS); OR
• Coronary artery disease with a documented prior MI and nonsustained VT, and a measured left ventricular ejection fraction (LVEF) less than or equal to 40% and inducible, sustained VT or VF at electrophysiology (EP) study (waiting periods required)*; OR
• Documented prior MI with measured LVEF less than or equal to 30% and New York Heart Association (NYHA) Class I on guideline-directed medical therapy (GDMT)** (waiting periods required)*; OR
• Ischemic cardiomyopathy (ICM) and documented prior MI and NYHA Class II or III and measured LVEF less than or equal to 35% (waiting periods required)*; OR
• ICM and documented prior MI and NYHA Class I and measured LVEF less than or equal to 30% (waiting periods required)*; OR
• Nonischemic cardiomyopathy (NICM) on GDMT** for greater than or equal to 90 days with NYHA Class II or III and measured LVEF less than or equal to 35% (less than or equal to 50% for HCM)11 (waiting periods required)*

Secondary Prevention of Sudden Cardiac Death

Humana members may be eligible under the Plan for an FDA-approved ICD for secondary prevention of SCD when the following criteria are met:

• Arrhythmogenic cardiomyopathy with high-risk factors for SCD (history of resuscitated SCA, sustained VT, ventricular dysfunction with RVEF or LVEF less than or equal to 45%) or syncope due to ventricular arrhythmia (VA); OR
• Episode of cardiac arrest due to VT/VF or hemodynamically unstable VT not due to a transient or reversible cause; OR
• Sustained VT, either spontaneous or induced by an EP study, not associated with an acute MI and not due to a transient or reversible cause; OR
• Syncope with a history of documented or inducible sustained VA or a diagnosed condition with a high risk of life-threatening VT (eg, familial, inherited or structural heart disease); OR
• NICM with a history of SCA, sustained VT or syncope caused by VA not due to a reversible cause;

AND ALL of the following:

• EFs must be measured by angiography, cardiac MRI, echocardiography or radionuclide scanning; AND
• MIs must be documented (if applicable) and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction; AND
• Absence of ALL of the following:
  • Any disease (eg, cancer, uremia, liver failure), other than cardiac, that is associated with a likelihood of survival less than 1 year; AND
  • Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; AND
  • Clinical symptoms or findings that would make the individual a candidate for coronary revascularization; AND
  • Irreversible brain damage from preexisting cerebral disease

*Waiting periods required. When indicated in the above criteria, an individual must be 40 days post-MI and/or 90 days post-revascularization prior to ICD insertion.

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Exceptions to these waiting periods include: Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0425-035 Page: 8 of 38 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Cardiac Pacemakers: An individual who meets the criteria listed above for an ICD may receive the combined device in one procedure at the time the pacemaker insertion is clinically indicated; OR
• Interim use of WCD: An individual who meets the criteria listed below for a WCD may receive a WCD when an ICD is not currently indicated or post-MI (the initial 40 days following an MI); OR
• Replacement of ICDs: An individual with an existing ICD may receive an ICD replacement due to the end of battery life, elective replacement indicator (ERI) or device/lead malfunction

Note: The criteria for ICDs are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Subcutaneous Implantable Defibrillators

Humana members may be eligible under the Plan for an FDA-approved subcutaneous implantable defibrillator (S-ICD) when the following criteria are met:

• Criteria listed above for an ICD are met; AND EITHER of the following:
• High risk for bacteremia (eg, individual on hemodialysis or with chronic indwelling endovascular catheters); OR
• Limited vascular access; AND absence of ALL of the following:
• Requires pacing or CRT; AND
• Incessant VT or spontaneous, frequently recurring VT that is reliably terminated with antitachycardia pacing; AND
• Symptomatic bradycardia91

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Replacement of S-ICDs:

An individual with an existing S-ICD may receive an S-ICD replacement due to the end of battery life, ERI or device malfunction.

Cardiac Resynchronization Therapy

Humana members may be eligible under the Plan for an FDA-approved CRT or CRT-D when the following criteria are met:

• NYHA Class III or (ambulatory) IV; AND
• LVEF less than or equal to 35%; AND
• Left bundle branch block (LBBB) with QRS duration greater than or equal to 120 milliseconds (ventricular dyssynchrony); OR
• Non-LBBB with QRS duration greater than or equal to 150 milliseconds; AND
• Sinus rhythm; AND
• Remains symptomatic despite GDMT**; OR
• NYHA Class II; AND
• LVEF less than or equal to 35%; AND
• LBBB with QRS duration greater than or equal to 120 milliseconds (ventricular dyssynchrony); AND
• Sinus rhythm; AND
• Remains symptomatic despite GDMT**; OR
• NYHA Class II to (ambulatory) Class IV; AND
• Nonobstructive HCM; AND
• LBBB with QRS duration greater than or equal to 120 milliseconds;

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• LVEF less than 50%; AND
• Sinus rhythm¹⁵; OR
• Atrial fibrillation; AND
• AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT; AND
• LVEF less than or equal to 35%; AND
• Remains symptomatic despite GDMT**; AND
• Requires ventricular pacing or otherwise meets the above CRT criteria

Replacement of CRT or CRT-Ds: Individual with an existing CRT or CRT-D may receive a CRT or CRT-D replacement due to the end of battery life, ERI or device/lead malfunction. **GDMT represents individualized optimal medical therapy for AF, HF and NICM and may include the following:

• Aldosterone antagonists
• Angiotensin-converting enzyme inhibitors (ACEI)
• Angiotensin receptor blockers (ARB)
• Angiotensin receptor-neprilysin inhibitors (ARNI)¹³
• Anticoagulants
• Beta blockers
• Digoxin
• Diuretics
• Ivabradine¹³
• Nitrates¹³
• SLGT2 inhibitors¹³

Note: The criteria for CRT or CRT-Ds are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

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Revision Date: 01/01/2024
Review Date: 03/01/2023
Policy Number: HUM-0425-035
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Wearable Cardioverter Defibrillators

Humana members may be eligible under the Plan for an FDA-approved WCD (eg, ASSURE System, ZOLL LifeVest) when the following criteria are met:

• Criteria listed above for an ICD are met (waiting period* exception may apply) and the individual is at high risk for SCD, but an ICD is currently not indicated in any of the following conditions:
• Awaiting heart transplantation; OR
• Awaiting ICD reimplantation following infection-related explantation; OR
• Systemic infectious process or other temporary condition (eg, new or worsening HF or peripartum cardiomyopathy during the GDMT** optimization period) that precludes implantation; OR
• Immediate post-MI period (the initial 40 days following an MI), with either a history of VT or VF at least 48 hours after the acute MI or an LVEF less than or equal to 35%; AND EITHER of the following:
• Individual is 18 years of age or older for ASSURE System or ZOLL LifeVest; OR
• Individual is 17 years of age or younger with a chest circumference of at least 26 inches and weighs at least 41 pounds for ZOLL LifeVest⁹⁰

Continuation of Coverage WCDs are initially authorized for 90 days and subject to medical necessity review every 30 days thereafter. Compliance is verified by ordering physician documented attestation. Compliance is defined as usage of the WCD for at least 23 hours per day over a 30 day period. Verification of compliance (physician attestation) may be requested at any time within the first 90 days of therapy and at any time thereafter.

Coverage Limitations

The following are considered integral to the primary device/procedure and not separately reimbursable including, but may not be limited to:

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Revision Date: 01/01/2024
Review Date: 03/01/2023
Policy Number: HUM-0425-035
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• Antibacterial envelopes (eg, Tyrx); OR
• Monitoring features/devices, stand-alone or integrated; OR
• Replacement of the following WCD-related items:
  • Batteries; OR
  • Electrodes; OR
  • Vests/garments

Humana members may NOT be eligible under the Plan for ICDs, CRTs/CRT-Ds or S-ICDs for any indications other than those listed above. These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for WCDs for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any of the following:

• Body surface activation mapping; OR
• CCM devices; OR
• CRT-Ds with hemodynamic (fluid status) monitoring lead; OR
• EV-ICDs (substernal implantable defibrillator); OR
• His bundle pacing; OR
• Left bundle branch pacing; OR
• WiSE wireless cardiac resynchronization therapy system

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for AEDs for home use. These are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 03/01/2023
Policy Number: HUM-0425-035
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Background

Additional information about cardiac disease may be found from the following websites:

• American Heart Association
• National Library of Medicine

Medical Alternatives

Alternatives to cardioverter defibrillators include, but may not be limited to, the following:

• Cardioversion
• Prescription drug therapy

Alternatives to CRTs/CRT-Ds include, but may not be limited to, the following:

• Heart transplantation (please refer to Solid Organ Transplants Medical Coverage Policy)
• Prescription drug therapy
• Surgical procedures (coronary revascularization, valvular replacement surgery and cardiac remodeling)
• Ventricular assist device (VAD) placement (please refer to Ventricular Assist Device (VAD), Total Artificial Heart (TAH) Medical Coverage Policy)

Physician consultation is advised to make an informed decision based on an individual's health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 03/01/2023
Policy Number: HUM-0425-035
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Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only.

Do not rely on the accuracy and inclusion of specific codes.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. Provider Claims Codes

• CPT® Code(s)
• Description P
• Comments

• 33206
• Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial
• Not Covered if used to report any procedure outlined in Coverage Limitations section

• 33207
• Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular
• Not Covered if used to report any procedure outlined in Coverage Limitations section

• 33208
• Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
• Not Covered if used to report any procedure outlined in Coverage Limitations section

• 33214
• Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)

• 33215
• Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode

• 33216
• Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator
• Not Covered if used to report any procedure outlined in Coverage Limitations section

• 33217
• Insertion of 2 transvenous electrodes, permanent pacemaker or

an implantable defibrillator

• 33218 Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator

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• 33220 Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator
• 33223 Relocation of skin pocket for implantable defibrillator
• 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)
• 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)
• 33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads
• 33231 Insertion of implantable defibrillator pulse generator only; with existing multiple leads
• 33234 Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular Not Covered if used to report any procedure outlined in Coverage Limitations section
• 33240 Insertion of implantable defibrillator pulse generator only; with existing single lead
• 33241 Removal of implantable defibrillator pulse generator only
• 33243 Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy
• 33244 Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction
• 33249 Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system

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• 33263 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system
• 33264 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system
• 33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed
• 33271 Insertion of subcutaneous implantable defibrillator electrode
• 33273 Repositioning of previously implanted subcutaneous implantable defibrillator electrode
• 33999 Unlisted procedure, cardiac surgery Not Covered if used to report any procedure outlined in Coverage Limitations section
• 93260 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 by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system
• 93261 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system

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• 93282 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 by a physician or other qualified health care professional; single lead transvenous implantable defibrillator system
• 93283 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 by a physician or other qualified health care professional; dual lead transvenous implantable defibrillator system
• 93284 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 by a physician or other qualified health care professional; multiple lead transvenous implantable defibrillator system
• 93287 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 by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system
• 93289 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements
• 93292 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system

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• 93295 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional
• 93296 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
• 93640 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement;
• 93641 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator
• 93642 Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
• 93644 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0425-035 Page: 19 of 38

this is the 93745

current version before utilizing. Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events 99457 Remote physiologic monitoring treatment management services, Clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes 99458 Remote physiologic monitoring treatment management services, Clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive . . F . communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure) CPT® Category Ill Code(s) Description Comments o408T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes Not Covered 0409T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when Y , ne ay .

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0425-035 Page: 20 of 38
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• 0411T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only - Not Covered
• 0412T Removal of permanent cardiac contractility modulation system; pulse generator only - Not Covered
• 0413T Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) - Not Covered
• 0414T Removal and replacement of permanent cardiac contractility modulation system pulse generator only - Not Covered
• 0415T Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) - Not Covered
• 0416T Relocation of skin pocket for implanted cardiac contractility modulation pulse generator - Not Covered
• 0417T 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, including review and report, implantable cardiac contractility modulation system - Not Covered
• 0418T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system - Not Covered
• 0515T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery]) - Not Covered
• 0516T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only - Not Covered

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0425-035 Page: 21 of 38

• 0517T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; pulse generator component(s) (battery and/or transmitter) only - Not Covered
• 0518T Removal of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing - Not Covered
• 0519T Removal and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter) - Not Covered
• 0520T Removal and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter), including placement of a new electrode - Not Covered
• 0521T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimulator for left ventricular pacing - Not Covered
• 0522T 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, including review and report, wireless cardiac stimulator for left ventricular pacing - Not Covered
• 0571T Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed - Not Covered
• 0572T Insertion of substernal implantable defibrillator electrode - Not Covered
• 0573T Removal of substernal implantable defibrillator electrode - Not Covered

Cardioverter Defibrillators/Cardiac Resynchronization Therapy Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0425-035 Page: 22 of 38 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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