CurrentBlue Cross Blue Shield - MassachusettsPolicy 118

Permanent Cardiac Pacemakers — Single‑ and Dual‑Chamber

Defines medical necessity and investigational (non‑covered) indications, coding, and prior authorization rules for implantation of single‑ and dual‑chamber permanent cardiac pacemakers for commercial members of Blue Cross Blue Shield Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPermanent Cardiac Pacemakers — Single‑ and Dual‑Chamber

Policy CodePolicy 118

Change TypeNew policy

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionObtain precertification/preauthorization for inpatient implantation procedures.

SourceLink

POLICY UPDATE CHANGES

New medical policy describing medically necessary and investigational indications: Effective 10/1/2024.

Covered and investigationalindications stated

Inpatient PA requiredauthorization rule

3 CPT codesprocedure codes listed

NCD referencedCMS national coverage reference

Coverage Criteria for Permanent Cardiac Pacemakers

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Medically Necessary Indications

Covered when ALL of the following are met:

Documented non-reversible symptomatic bradycardia due to sinus node dysfunction: Documented non‑reversible symptomatic bradycardia due to sinus node dysfunction (symptoms attributable to heart rate < 60 beats per minute such as syncope, seizures, congestive heart failure, dizziness, or confusion).heart rate < 60 bpm with attributable symptoms

Supported by CMS determination referenced in policy.

Documented non-reversible symptomatic bradycardia due to second- or third-degree AV block: Documented non‑reversible symptomatic bradycardia due to second‑degree and/or third‑degree atrioventricular block.N/A

Listed as medically necessary indication.

Investigational / Not Covered Indications

Not covered / investigational when ANY of the following apply:

Reversible causes of bradycardia: Bradycardia due to reversible causes such as electrolyte abnormalities, medications or drugs, and hypothermia.reversible cause present

Listed as non‑covered.

Asymptomatic conduction abnormalities: Asymptomatic first‑degree atrioventricular block; asymptomatic sino‑atrial block or sinus arrest; asymptomatic sinus bradycardia; asymptomatic second‑degree AV block of Mobitz type unless QRS complexes are prolonged or electrophysiological studies show block at/below the His bundle; right bundle branch block with left axis deviation or other fascicular/bundle branch block without syncope.asymptomatic

Multiple specific asymptomatic conditions listed as investigational/non‑covered.

Conditions without symptomatic bradycardia or only intermittent brief pacing: Ineffective atrial contractions (for example, chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia; a clinical condition in which pacing takes place only intermittently and briefly and is unlikely to become prolonged.no symptomatic bradycardia or only intermittent/brief pacing

Listed as investigational/non‑covered.

Syncope of undetermined cause and other listed non-covered indications: Syncope of undetermined cause; bradycardia during sleep; asymptomatic bradycardia in certain post‑myocardial infarction patients about to initiate long‑term beta‑blocker therapy; frequent or persistent supraventricular tachycardias except when pacemaker is specifically for control of tachycardia.undetermined cause or listed condition present

Included in investigational/non‑covered list.

This policy follows the CMS National Coverage Determination (Decision Memo CAG-00063R3) scope and therefore excludes certain device types and services from coverage under this policy. Specifically, biventricular pacemakers, pacemakers that stimulate more than two heart chambers, devices intended to treat tachyarrhythmias or cardiac dyssynchrony, cardiac resynchronization therapy devices, cardiac pacemaker evaluation services, and self-contained pacemaker monitors are outside the scope of this NCD and are addressed separately.

The policy lists specific conditions for which implantation of single‑ or dual‑chamber permanent pacemakers is considered investigational / not covered. These include reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia; asymptomatic conduction abnormalities (including asymptomatic first‑degree AV block, asymptomatic sino‑atrial block or sinus arrest, asymptomatic sinus bradycardia, and asymptomatic second‑degree AV block of Mobitz type unless prolonged QRS or EPS demonstrate block at/below the His bundle); ineffective atrial contractions (for example chronic atrial fibrillation or flutter or giant left atrium) without symptomatic bradycardia; bradycardia during sleep; syncope of undetermined cause; right bundle branch block with left axis deviation or other fascicular/block without syncope; asymptomatic bradycardia in post‑MI patients about to initiate long‑term beta‑blocker therapy; frequent or persistent supraventricular tachycardias except when the pacemaker is specifically for tachycardia control; and clinical situations where pacing is only intermittent and brief and not likely to become prolonged.

Procedure and Diagnosis Coding

Covered CPT CodesCPTCovered

33206	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial.
33207	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular.
33208	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

Example ICD Diagnosis Codes referencedICD-10

G90.01	Carotid sinus syncope (listed as column 2 accompaniment in diagnosis table).
Q24.6	Congenital heart block (appears in diagnosis table).

Bradycardia symptom threshold

Heart rate thresholdHeart rate less than 60 beats per minute

Associated symptomsSyncope, seizures, congestive heart failure, dizziness, or confusion

Clinical contextSymptoms must be directly attributable to the bradycardia (heart rate < 60 bpm)

Related indicationsDocumented non-reversible symptomatic bradycardia due to sinus node dysfunction or second- or third-degree AV block

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required when the procedure is performed as an inpatient for all products. Outpatient prior authorization requirements vary by product: Commercial Managed Care (HMO and POS) — outpatient prior authorization is not required; Commercial PPO and Indemnity — outpatient prior authorization requirements may apply per product and should be verified prior to service.

Inpatient: Precertification/preauthorization required for all products.
Outpatient: Commercial Managed Care (HMO and POS) — prior authorization not required.
Outpatient: Commercial PPO and Indemnity — verify prior authorization requirements with payer/product.

Billing Rule

Coding and Submission Guidance

Providers should report all services using the most up-to-date industry-standard procedure (CPT), HCPCS, revenue, and ICD-10 diagnosis codes, and include applicable modifiers. Inclusion of a code in policy does not guarantee coverage or payment; check the member's contract benefits and ensure the medical necessity criteria in this policy are met before billing. The codes listed in this policy are informational and not all-inclusive.

Report services with current CPT/HCPCS/ICD-10 codes and applicable modifiers.
Verify coverage and member benefits at time of service.
Ensure medical necessity criteria in the policy are met for code reimbursement.

Step Therapy

No step therapy requirements are specified in this policy for the services described.

OpenPayer

Permanent Cardiac Pacemakers — Single‑ and Dual‑Chamber

Coverage Criteria for Permanent Cardiac Pacemakers

Procedure and Diagnosis Coding

Provider Requirements and Authorization

Background

Definitions

Revision History