LCD : Resynchronization for Congestive Heart Failure (L17645)

LCD for Resynchronization for Congestive Heart Failure (L17645)

Contractor Information

Contractor Name ^{back to top}
BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)
Contractor Number ^{back to top}
00390
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}
L17645

LCD Title ^{back to top}
Resynchronization for Congestive Heart Failure

Contractor's Determination Number ^{back to top}
L17645

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ? 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1862 (a)(7) This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) This section allows coverage and payment for only those services considered medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833 (e) This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction ^{back to top}
New Jersey Tennessee

Secondary Geographic Jurisdiction ^{back to top}
Alaska Alabama Arkansas Arizona California Colorado Connecticut Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi North Carolina North Dakota Nebraska New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Oversight Region ^{back to top}
Region IV


Original Determination Effective Date ^{back to top}
For services performed on or after 07/15/2002

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 11/18/2006

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
< Indications Resynchronization Therapy will be covered for patients with symptomatic congestive heart failure who have a functional NYHA classification of Class III or Class IV, and who have an IVCD on their surface ECG. Limitations The patients must be symptomatic despite conventional therapy with ACE (angiotensin converting enzyme) inhibitors and beta blockers as well as other appropriate pharmacologic measures. The patient must have systolic dysfunction and must have an ejection fraction of less than 35% on echocardiogram or gated nuclear studies. The surface ECG must demonstrate a QRS duration of at least 130ms in the lead with the widest interval. The patient's intrinsic rhythm must not be atrial fibrillation. Resynchronization therapy is only covered for devices specifically approved by the Food and Drug Administration (FDA) for this indication. The use of non-approved devices will be considered investigational and will not be covered except under an IDE exemption. Combined pacemaker/defibrillators will be covered under this policy only if: a. The patient meets the requirements of this policy and also meets the currently prevailing standards for implantable defibrillators (NCD, LCD or standard of care, as applicable) OR b. The cost of the pacemaker/defibrillator does not exceed the cost of a comparable pacemaker or Medicare is not billed for the additional cost.

Coverage Topic ^{back to top}
Outpatient Hospital Services

Coding Information

Bill Type Codes: ^{back
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Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back
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Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0360	Operating room services-general classification

CPT/HCPCS Codes ^{back
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One or more of the following procedure codes should be used to describe the initiation of resynchronization therapy:

33208	INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR
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 PACING CARDIOVERTER-DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE
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)
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) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
33226	REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF GENERATOR)
33241	SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR
33243	REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR ELECTRODE(S); BY THORACOTOMY
33244	REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION
33249	INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR

ICD-9 Codes that Support Medical Necessity ^{back
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Primary Diagnosis Codes

Pacemaker insertion for the purpose of Cardiac Resynchronization Therapy should carry one of the following as the primary diagnosis. Pacemaker insertion for other indications (e.g. IVCD) should not carry these diagnoses as the primary diagnosis but should carry the other indication as the primary diagnosis.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The indications in the text of the policy must be applicable for the procedure to be paid. The use of these codes must therefore be verified by the presence of NYHA Class III or IV heart failure and the presence of IVCD. Documentation is not required with claim submission but must be available on request.

428.0	CONGESTIVE HEART FAILURE UNSPECIFIED
428.1	LEFT HEART FAILURE
428.20	UNSPECIFIED SYSTOLIC HEART FAILURE
428.22	CHRONIC SYSTOLIC HEART FAILURE
428.33	ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
428.40	UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
428.42	CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
428.43	ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
428.9	HEART FAILURE UNSPECIFIED

Secondary Codes:

When the above primary ICD-9-CM codes are used, indicating that the procedure is being performed for the purpose of resynchronization, it must be accompanied by a secondary ICD-9-CM codes to identify the IVCD.

426.2	LEFT BUNDLE BRANCH HEMIBLOCK
426.3	OTHER LEFT BUNDLE BRANCH BLOCK
426.4	RIGHT BUNDLE BRANCH BLOCK
426.50	BUNDLE BRANCH BLOCK UNSPECIFIED
426.51	RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK
426.52	RIGHT BUNDLE BRANCH BLOCK AND LEFT ANTERIOR FASCICULAR BLOCK
426.53	OTHER BILATERAL BUNDLE BRANCH BLOCK

Diagnoses that Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity ^{back
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Use of any secondary ICD-9 code not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy will be denied when CHF is listed ias the primary reason for the procedure.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back
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Diagnoses that DO NOT Support Medical Necessity ^{back
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N/A

General Information

Documentation Requirements ^{back
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Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned.

The standard operative note should reflect an indication of the procedure and a description of procedure treatment. Special focus should be made in describing the placement of the coronary sinus lead including any technical difficulties or complications. The FDA approved system must be noted in the record.

A functional classification of the patient's heart failure, including appropriate diagnostic studies must be available.

Documentation must be available to Medicare upon request.

Appendices ^{back
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LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines ^{back
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N/A

Sources of Information and Basis for Decision ^{back
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Saxon, Leslie, MD et al, "Devices in heart failure: Pacemakers", UpToDate®, Vol. 9 No. 3

Gerber, Thomas, MD et al "Left Ventricular and Biventricular Pacing in Congestive Heart Failure", Mayo Clin Proc. 2001; 76:803-812

The Medtronic InSync® Cardiac Resynchronization System, statement

Arrhythmia News, Continuum Heart Institute, St. Luke's-Roosevelt Hospital Center, Volume 7 Issue 2.

Adopted from Contract Carrier: Empire Medicare Services

Advisory Committee Meeting Notes ^{back
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Start Date of Comment Period ^{back
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06/29/2004

End Date of Comment Period ^{back
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08/12/2004

Start Date of Notice Period ^{back
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08/13/2004

Revision History Number ^{back
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17645a

Revision History Explanation ^{back
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This LCD was converted from an LMRP on 6/23/2004

11/18/2006 - The description for CPT/HCPCS code 33224 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code 33225 was changed in group 1

Reason for Change ^{back
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Last Reviewed On Date ^{back
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06/28/2007