Implantable Wireless Pulmonary Artery Pressure Monitoring
Customize your policy alerts
Sign up for Arizona Complete Health Policy CP.MP.160 alerts
Get alerted when Policy CP.MP.160 changes without checking for updates manually.
Monitor payer policy activity
Policy governing the coverage stance and clinical evidence for implantable wireless pulmonary artery (PA) pressure monitoring devices (e.g., CardioMEMS) for management of heart failure among Arizona Complete Health members.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage determination
Policy statement
Applies to health plans affiliated with Centene Corporation as stated.
The CardioMEMS HF System is contraindicated in patients who have an inability to take dual antiplatelet therapy or anticoagulants for one month post-implant. The device is a permanently implanted pulmonary artery (PA) sensor intended to transmit daily PA pressure measurements to guide outpatient heart failure management, but current evidence is limited. The largest randomized trial (CHAMPION) demonstrated reduced HF hospitalizations at six months (31% vs 44%) and a low reported device- or procedure-related complication rate (approximately 1%), but study limitations and regulatory concerns leave uncertainty about long-term safety and effectiveness and applicability beyond the FDA-approved population.
Because of those evidence gaps and the explicit contraindication for patients unable to tolerate short-term antiplatelet/anticoagulant therapy, implantation should not be performed in patients who cannot adhere to or safely receive an appropriate post-procedure antithrombotic regimen for the first month after device placement.
Coverage determinations under this clinical policy are guidelines to assist in medical necessity decisions but do not override the member's benefit contract. All coverage is subject to the terms, conditions, exclusions and limitations of the member's coverage documents (for example, evidence of coverage or policy contract) and to applicable state and federal law. When state Medicaid provisions conflict with this policy, state Medicaid requirements take precedence.
Ambulatory cardiac hemodynamic monitoring using an implantable pulmonary artery pressure measurement device is considered not proven / experimental for management of heart failure in the outpatient setting due to insufficient evidence on long-term health benefits (including survival), safety, and quality of life. The policy notes a lack of data supporting accuracy and clinical utility outside the studied NYHA Class III population and references concerns about study limitations and potential sponsor influence.
Coding
| 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. |
| C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components |
Provider Actions & Authorization
Prior authorization and coding: include CPT/HCPCS codes
Coverage references CPT codes 33289 and 93264 and HCPCS code C2624; any request for implantation or remote monitoring should be submitted with the appropriate CPT/HCPCS codes and prior authorization per plan rules.
- 33289 — Transcatheter implantation of wireless pulmonary artery pressure sensor including deployment, calibration, right heart catheterization, selective pulmonary catheterization, radiological supervision/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, interpretation, trend analysis, and reports.
- C2624 — Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components.
Review NCDs/LCDs and member benefits before authorization
This clinical policy is a guide to medical necessity only; providers must review applicable Medicare NCDs/LCDs and the member’s benefit documents prior to requesting authorization.
- Review all applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for Medicare members.
- Verify member-specific coverage, exclusions, and benefit limitations in the enrollee’s plan documents before submitting an authorization request.
Step therapy requirements
No step therapy requirements are specified in this clinical policy section.
No labeled action
(No additional provider action specified in source.)
Required procedural and remote-monitoring documentation
Operative and device documentation must support transcatheter implantation and calibration of the PA sensor and any right heart catheterization/pulmonary angiography performed; include documentation of remote monitoring downloads and physician interpretation as described by the CPT/HCPCS coding.
- Include operative report details of sensor deployment and calibration.
- Document right heart catheterization and selective pulmonary catheterization or angiography if performed.
- Retain records of at least weekly remote monitoring downloads, clinician interpretation, trend analysis, and reports as described in CPT 93264.
Provider attestation via claims
By submitting claims or providing services to members, providers agree to be bound by the terms and conditions of this clinical policy as independent contractors.
- Providers are independent contractors and not agents or employees of the Health Plan.
- Submission of claims constitutes agreement to the policy’s terms when no separate contract exists.
Coverage stance: not proven for any indication
The long-term safety and effectiveness of implantable wireless pulmonary artery pressure monitoring has not been proven for any indication; coverage may be denied on that basis.
Coverage decision constraints and governance
Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member’s coverage documents and to state and federal requirements; where state Medicaid provisions conflict with this policy, state Medicaid provisions take precedence.
- Coverage and administration of benefits are governed by the member’s evidence of coverage, certificate, policy, or contract.
- Legal and regulatory requirements supersede this clinical policy when discrepancies exist.
Background
Heart failure (HF) is a common cause of hospitalization and is characterized by dyspnea, fatigue, and fluid retention. The implantable wireless pulmonary artery pressure monitoring system (CardioMEMS) consists of a dime-sized PA sensor implanted via fluoroscopy-guided right-heart catheterization, a transvenous delivery catheter, and home monitoring components that wirelessly transmit systolic, diastolic, and mean PA pressures to a secure database for clinician review. The intended clinical rationale is that remote, daily hemodynamic data allow clinicians to optimize outpatient medical management and potentially reduce HF-related hospitalizations.
Clinical trial evidence (notably the CHAMPION trial) has shown reductions in HF-related admissions in a selected population (NYHA Class III with prior hospitalization), with a low reported device- or procedure-related complication rate (~1%). However, limitations in the evidence base—including limited long-term safety and mortality data, incomplete quality-of-life information, and potential for sponsor influence—mean that the long-term effectiveness, generalizability to other NYHA classes, and overall risk/benefit profile remain uncertain.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.