Humana Cardiac Pacemakers - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories NCD NCD NCD NCD NCD LCA LCA LCA LCA LCA Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers Cardiac Pacemaker Evaluation Services Leadless Pacemakers Self-Contained Pacemaker Monitors Transtelephonic Monitoring of Cardiac Pacemakers 20.8.3 20.8.1 20.8.4 20.8.2 20.8.1.1 Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker A54958 Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker A54961 A54931 Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker A54982 LCD LCA Cardiac Rhythm Device Evaluation L34833 A56602 Cardiac Pacemakers Page: 2 of 10 J5 - Wisconsin Physicians Service Insurance Corporation J8 - Wisconsin Physicians Service Insurance Corporation J15 - CGS Administrators, LLC (Part A/B MAC) IA, KS, MO, NE IN, MI KY, OH A54929 JE - Noridian Healthcare Solutions, LLC CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AR, CO, NM, OK, TX, LA, MS DE, D.C., MD, NJ, PA DE, D.C., MD, NJ, PA JF - Noridian Healthcare Solutions, LLC JH - Novitas Solutions, Inc. (Part A/B MAC) JL - Novitas Solutions, Inc. (Part A/B MAC) JH - Novitas Solutions, Inc. (Part A/B MAC) Billing and Coding: Cardiac Rhythm Device Evaluation LCA LCA LCA Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker A54831 Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker A54909 Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers A54926 Cardiac Pacemakers Page: 3 of 10 DE, D.C., MD, NJ, PA AL, GA, TN NC, SC, VA, WV IL, MN, WI CT, NY, ME, MA, NH, RI, VT FL, PR, U.S. VI JL - Novitas Solutions, Inc. (Part A/B MAC) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part A/B MAC JN - First Coast Service Options, Inc. (Part A/B MAC) Description Permanent Pacemakers Permanent cardiac pacemakers are self-contained, battery-operated devices that send electrical stimulation to the heart through one or more implanted leads. Single chamber pacemakers use a single atrial or ventricular lead to deliver electrical stimulation. Dual chamber pacemakers stimulate both the atrium and the ventricle with a lead in both chambers. Cardiac arrhythmias occur when the heart beats irregularly, too slow or too fast. These arrhythmias develop due to dysfunction in the generation and/or conduction of signals in the electrical system of the heart. Symptoms of bradycardia (heart rate less than 60 beats per minute) attributable to electrical system dysfunction include confusion, congestive heart failure, dizziness, seizures and/or syncope. Pacemakers treat bradycardia arising from sinus node dysfunction or atrioventricular block by delivering electrical stimulation to the cardiac muscle to pace activity in the absence of intrinsic (natural) pacing and to sense the heart’s intrinsic signals to pace accordingly. The implantation procedure is typically performed under local anesthesia. A catheter is inserted into the chest and the pacemaker’s leads are threaded through the catheter to the appropriate chamber(s) of the Cardiac Pacemakers Page: 4 of 10 heart. The surgeon then makes a small pocket in the pad of the flesh under the skin on the upper portion of the chest wall to hold the pulse generator (pacemaker). The pocket is then closed with stitches. Leadless Pacemakers A single-chamber leadless cardiac pacemaker is a small, battery-operated electrical device placed in the right ventricle of the heart that is reported to aid in maintaining a regular heart rhythm. The device is delivered directly to the ventricle through a catheter inserted into the femoral vein and attaches to the cardiac tissue with fixation tines or coils. Unlike traditional pacemakers, leadless cardiac pacemakers do not require intravascular leads. Examples of single-chamber leadless cardiac pacemakers approved by the US Food & Drug Administration (FDA) include, but may not be limited to, Aveir VR Leadless System and Micra Transcatheter Pacing System (Micra AV2, Micra VR2). Leadless pacemakers are also available as dual-chamber devices which purportedly regulate the heart rate synchronously between leadless pacemakers placed in the right ventricle and the right atrium. The Aveir DR Dual Chamber Leadless Pacemaker System is an example of an FDA-approved dual-chamber leadless pacemaker. Purported benefits of a leadless cardiac pacemaker include elimination of lead failure or migration and reduction of blood clots or infection that may occur with conventional transvenous pacemakers. A pacemaker is generally indicated for a symptomatic individual experiencing conditions including, but not limited to, bradycardia and/or atrial fibrillation. All pacemakers require routine in-person or telephonic checks by a cardiologist every 3 to 6 months to ensure they are working as intended. Batteries for both permanent and leadless pacemakers are intended to last for 5 to 17 years. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. Please refer to the above CMS guidance for permanent cardiac pacemakers, leadless pacemakers and pacemaker monitoring. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines. The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations Cardiac Pacemakers Page: 5 of 10 US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage