Obtain prior authorization for listed VAD procedures and HCPCS supplies

Prior authorization is required for VAD procedures and the listed HCPCS supplies/accessories. This includes implantation, removal, replacement, percutaneous insertion/removal procedures and the HCPCS supply codes enumerated in the policy.

• Covered CPT codes include 33975–33983, 33990–33992.
• Covered HCPCS supply/accessory codes include Q0478–Q0489 and Q0508.

Verify Medicare and Medicaid coverage rules before submission

Review Medicare NCDs, LCDs, and Medicare Coverage Articles for Medicare members before applying this policy; for Medicaid members, follow state Medicaid manual provisions when state coverage conflicts with this policy.

• Medicare: review applicable NCDs, LCDs, and Coverage Articles via CMS prior to applying the policy.
• Medicaid: state Medicaid coverage provisions take precedence — refer to the state Medicaid manual.

Document prior optimal medical management (step therapy)

Document prior optimal medical management before requesting destination therapy VAD. Evidence must show trials of guideline-directed therapy (including beta‑blockers and ACE inhibitors, if tolerated) for the required duration.

• No response to optimal medical management (including beta‑blockers and ACE inhibitors, if tolerated) for at least 45 of the last 60 days is required when claiming lack of response.
• Other destination-therapy pathways include balloon pump dependence ≥7 days or IV inotrope dependence ≥14 days, or CI <2.2 L/min/m2 with specified supporting criteria.

Attach explicit provider note summarizing indication and rationale

Include a clear provider note that states the indication, urgency, and that clinical criteria and prior therapies were considered when recommending VAD therapy.

• State the specific indication (bridge to recovery, bridge to transplant, or destination therapy).
• Confirm review of medical therapy trials and physiologic thresholds in the provider note.
• Acknowledge the provider’s professional judgment and that documentation supports medical necessity per the Health Plan.

Provide required clinical documentation to demonstrate indication, prior support, and contraindication status

Submit clinical documentation that demonstrates the specific indication (bridge to recovery, bridge to transplant, or destination therapy), prior respiratory/cardiac support and physiologic measures, and absence of contraindications to support medical necessity.

• Indication detail: bridge to recovery, bridge to transplant, or destination therapy (NYHA Class IV ≥90 days and life expectancy ≤2 years where applicable).
• Physiologic measures: LVEF ≤25%; peak VO2 ≤14 ml/kg/min (unless exceptions apply); cardiac index <2.2 L/min/m2 where applicable.
• Prior support: documentation of balloon pump dependence, IV inotrope dependence, duration of medical management (e.g., 45 of last 60 days).
• Contraindications: document absence of factors such as life expectancy ≤2 years (unrelated to heart disease), recent malignancy, irreversible organ dysfunction, noncompliance/caregiver insufficiency, or active substance use without evidence of risk reduction.

Maintain documentation and exercise professional medical judgment

Providers are responsible for exercising professional medical judgment and for maintaining documentation that supports medical necessity in accordance with the Health Plan and applicable legal/regulatory requirements.

• Documentation must support the clinical decision and compliance with the member’s coverage terms.
• Providers remain responsible for treatment decisions; the policy does not dictate clinical care.

Coverage contingent on meeting all clinical criteria — risk of denial if criteria not met

Coverage is granted only when all medical necessity criteria are met; requests that do not meet the indication, physiologic thresholds, durations of prior therapies, or absence of contraindications risk denial as not medically necessary.

• Key thresholds include LVEF ≤25%, CI <2.2 L/min/m2, peak VO2 ≤14 ml/kg/min (with exceptions), and required durations of prior therapies (e.g., 45 of last 60 days).
• Absence of listed contraindications is required for implantable VAD coverage.

Verify member contract terms and state-specific provisions

Coverage decisions are subject to the member’s contract terms, exclusions, and limitations; when state Medicaid provisions conflict with this policy, state rules govern.

• Verify the member’s contract, exclusions, and limitations prior to authorization determination.
• For Medicaid members, follow the state Medicaid manual where conflicts exist.