CurrentAmbetter NevadaPolicy CP.MP.160

Implantable Wireless Pulmonary Artery Pressure Monitoring

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Defines the payer's stance on implantable wireless pulmonary artery (PA) pressure monitoring devices (e.g., CardioMEMS) for heart failure management and the conditions under which they are considered or not. Applies to Ambetter Nevada members (non‑Medicare plans referenced in the log).

Policy Summary

PayerAmbetter Nevada

PolicyImplantable Wireless Pulmonary Artery Pressure Monitoring

Policy CodePolicy CP.MP.160

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for procedures and supplies referenced by CPT 33289, 93264 and HCPCS C2624 per payer coding guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentAmbetter NevadaPolicy CP.MP.160

Implantable Wireless Pulmonary Artery Pressure Monitoring

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Policy Summary

PayerAmbetter Nevada

PolicyImplantable Wireless Pulmonary Artery Pressure Monitoring

Policy CodePolicy CP.MP.160

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for procedures and supplies referenced by CPT 33289, 93264 and HCPCS C2624 per payer coding guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

device with FDA approval noted

1%reported complication rate

33289, 93264, C2624codes referenced

NYHA Class IIIFDA-approved population

Policy noticespolicy notices

Coverage Determination

Coverage stance

Not supported for long-term use:

Policy statement: The long-term safety and effectiveness of implantable wireless pulmonary artery pressure monitoring has not been proven for any indication, including the management of heart failure.

Applies to health plans affiliated with Centene Corporation; refer to Medicare-specific policy MC.CP.MP.160 for Medicare members.

The available clinical evidence does not demonstrate consistent long-term benefit for implantable wireless pulmonary artery (PA) pressure monitoring. The CHAMPION randomized trial showed a reduction in heart-failure (HF)–related hospitalizations at 6 months (31% vs 44%) and analyses reported sustained reductions at an average 18-month follow-up; however, important limitations remain including lack of mortality data, incomplete baseline quality-of-life information, and concerns about sponsor influence on study conduct. The evidence base lacks robust data on long-term health benefits (including survival), safety, and quality of life, and there is insufficient evidence to support use outside the trial population (FDA- and trial-population referenced as NYHA Class III).

Given the limited long-term safety and effectiveness data, implantable wireless pulmonary artery pressure monitoring is considered not supported/experimental for long-term use. The policy concludes that the long-term safety and effectiveness of these devices has not been proven for any indication, including outpatient management of heart failure, and therefore current evidence is insufficient to support routine coverage.

Coverage determinations under this policy are made in the context of the member's plan documents. All services remain subject to the terms, conditions, exclusions, and limitations of the applicable evidence of coverage, certificate of coverage, policy, or contract. State Medicaid provisions and other legal or regulatory requirements take precedence where they conflict with this clinical policy.

Procedure and Supply Codes

Procedure CPT codesCPT

33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed.
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional

HCPCS supply/device codeHCPCS

C2624

Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization and Coverage Alignment

Prior authorization is required. Review applicable coverage documents and obtain prior authorization before scheduling procedures or supplies related to implantable wireless pulmonary artery pressure monitoring. For Medicare members, review applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to approval.

Affected codes: CPT 33289, CPT 93264, HCPCS C2624.
Inclusion of codes in this policy does not guarantee coverage; verify plan-specific coding guidance prior to claim submission.

Step Therapy

Step Therapy / Sequencing Note

There is no formal step therapy requirement specified in this policy. Clinical guideline recommendations indicate invasive hemodynamic monitoring is primarily for acute or uncertain cases (e.g., respiratory distress or impaired systemic perfusion) rather than routine outpatient management. Consider guideline-directed sequencing of therapies and document why less invasive management is insufficient when requesting authorization.

Clinical Background and Evidence

Heart failure is a leading cause of hospitalization and readmission. Implantable wireless PA pressure sensors (for example, the CardioMEMS HF System) are small, implantable sensors placed via right-heart catheterization that transmit daily systolic, diastolic, and mean PA pressures to clinicians with the goal of guiding outpatient HF therapy and reducing HF hospitalizations. The largest randomized trial (CHAMPION) demonstrated reduced HF hospitalization rates in the device-guided group, but the overall evidence is limited by concerns about study conduct, sparse mortality and long-term safety data, and uncertainty about benefit outside the NYHA Class III population.

Key Terms and Device Definitions

CardioMEMS HF System — implantable pulmonary artery sensor description

Device nameCardioMEMS HF System

DescriptionDime-sized implantable pulmonary artery (PA) sensor permanently placed in the pulmonary artery via fluoroscopy-guided right‑heart catheterization

ComponentsTransvenous catheter delivery system, patient home monitoring electronic system (pillow antenna, bedside unit, remote button), and secure internet-accessible database

Measurements capturedDaily systolic, diastolic, and mean pulmonary artery pressures (each reading captures 18 seconds of pressure data)

Contraindication notedContraindicated for patients unable to take dual antiplatelet or anticoagulant therapy for one month post‑implant

NYHA Class III — symptomatic heart failure classification

Policy Summary

PayerAmbetter Nevada

PolicyImplantable Wireless Pulmonary Artery Pressure Monitoring

Policy CodePolicy CP.MP.160

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for procedures and supplies referenced by CPT 33289, 93264 and HCPCS C2624 per payer coding guidance.

SourceLink

On This Page

Policy position: long-term safety and effectiveness for outpatient use not proven — increased denial risk if criteria not met.
Clinical guidance: ACCF/AHA 2022 supports pulmonary artery catheter monitoring in select acute settings.

Documentation Required

Suggested Clinical Documentation and Denial Risk

Document thoroughly to support medical necessity and reduce denial risk. Include device model, indication (e.g., NYHA class), history of prior heart failure hospitalizations, inability to manage via noninvasive means, anticoagulation/antiplatelet status, and details of prior and current medical therapy. Note that the long-term safety and effectiveness of implantable wireless PA pressure monitoring has not been proven for any indication — absence of supporting documentation may lead to denial.

Suggested documentation items: device model and manufacturer; indication and NYHA classification; recent HF hospitalizations and dates; prior therapies tried and response; rationale why invasive monitoring is necessary; antiplatelet/anticoagulation plan.
Denial risk: lack of evidence for long-term benefit; failure to meet policy or plan terms/limitations may result in non-coverage.

Note

Administrative and Contractual Notices

Providers and representatives are bound by the Health Plan terms and conditions. Unauthorized copying, distribution, or use of this clinical policy is prohibited. Coverage decisions are subject to all plan terms, exclusions, and limitations; when state Medicaid provisions conflict with this policy, state provisions prevail for Medicaid members.

Medicare members: review NCDs/LCDs and Medicare Coverage Articles prior to applying policy criteria.
Contractual note: providers are independent contractors; policy is property of the Health Plan.

TermNYHA Class III

DefinitionSymptomatic heart failure classification in the New York Heart Association (NYHA) Functional Classification system representing marked limitation of physical activity but comfortable at rest

Relevance to policyPopulation referenced for FDA approval and the primary trial (CardioMEMS indicated for NYHA Class III patients with a prior HF hospitalization within the previous year)

Use in device studiesNYHA Class III was the eligibility/target population for the CHAMPION trial and FDA approval as described in the policy background

Implantable wireless pulmonary artery pressure sensor — general device definition

DefinitionAn implantable wireless pulmonary artery pressure sensor is a permanently implanted device that transmits pulmonary artery hemodynamic data to clinicians to guide heart failure management

Typical form factorDime‑sized sensor implanted in the pulmonary artery

Data transmission and monitoringSensor readings are captured wirelessly (18 seconds per reading) and transmitted via a home monitoring system to a secure database for clinician access

Intended clinical useUsed to provide daily PA pressure measurements to assist clinicians in optimizing medical management to potentially reduce HF‑related hospitalizations