ModifiedBlue Cross Blue Shield - NebraskaPolicy M.30

MA Permanent Cardiac Pacemakers (Preauthorization Required)

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Defines medical necessity, coverage criteria, non-covered indications, and required preauthorization for implantation, replacement, and certain procedures for permanent single- and dual-chamber pacemakers and ICDs for Blue Cross Blue Shield - Nebraska.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Permanent Cardiac Pacemakers (Preauthorization Required)

Policy CodePolicy M.30

Change TypeMaterial updates — codes addedMCG criteria added

Effective DateJan 1, 2026

Next Review DateAug 5, 2026

Key ActionObtain preauthorization for the listed permanent pacemaker and implantable defibrillator procedures using the policy's specified codes.

SourceLink

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ModifiedBlue Cross Blue Shield - NebraskaPolicy M.30

MA Permanent Cardiac Pacemakers (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.30 alerts

Get alerted when Policy M.30 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Permanent Cardiac Pacemakers (Preauthorization Required)

Policy CodePolicy M.30

Change TypeMaterial updates — codes addedMCG criteria added

Effective DateJan 1, 2026

Next Review DateAug 5, 2026

Key ActionObtain preauthorization for the listed permanent pacemaker and implantable defibrillator procedures using the policy's specified codes.

SourceLink

POLICY UPDATE CHANGES

Additional codes added to this policy effective 06/01/2026.

Starting 06/01/2026 MCG criteria will be utilized if needed in addition to CMS guidelines.

NCD 20.8.3 / 20.4Primary CMS NCDs referenced

CPT/HCPCS listProcedure codes enumerated

06/01/2026New codes / MCG apply

AllowedReplacement ICD covered

BCBSNEApplies to

Coverage Criteria for Pacemakers and ICDs

Single or Dual Chamber Permanent Cardiac Pacemakers (NCD 20.8.3)

Covered when ONE of the following indications is documented:

Primary indications: A. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction OR B. Documented non-reversible symptomatic bradycardia due to second degree and/or third-degree atrioventricular block

Per NCD 20.8.3

Non-covered indications for pacemakers (NCD 20.8.3)

Devices are non-covered when any of the following apply:

Non-covered conditions: Reversible causes of bradycardia (electrolyte abnormalities, medications or drugs, hypothermia); asymptomatic first-degree atrioventricular block; asymptomatic sinus bradycardia; asymptomatic sino-atrial block or asymptomatic sinus arrest; ineffective atrial contractions (eg chronic atrial fibrillation or flutter, giant left atrium) without symptomatic bradycardia; asymptomatic Mobitz Type I second-degree AV block unless QRS prolonged or electrophysiological studies show block at or beyond His bundle; syncope of undetermined cause; bradycardia during sleep; right bundle branch block with left axis deviation (and other fascicular or bundle branch block) without syncope or symptoms of intermittent AV block; asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker therapy; frequent or persistent supraventricular tachycardias except when pacemaker is specifically for tachycardia control; clinical conditions in which pacing is intermittent and unlikely to become prolonged

Per NCD 20.8.3 list

Implantable Cardioverter Defibrillator (NCD 20.4) - Ventricular tachyarrhythmia and post-MI/non-ischemic cardiomyopathy indications

ICD may be considered reasonable and necessary when specified AND/OR conditions are met as follows:

VT or cardiac arrest indication: A. Personal history of sustained ventricular tachyarrhythmia (VT) or cardiac arrest due to ventricular fibrillation (VF) AND B. Patient is clinically stable AND C. The sustained VT episode was not associated with a myocardial infarction and not due to a transient or reversible cause OR D. The cardiac arrest episode due to VF was not due to a transient or reversible cause

Per NCD 20.4

Post-myocardial infarction indication: A. Previous myocardial infarction and documented left ventricular ejection fraction ≤ 0.30 (measured by echocardiography, radionuclide imaging, cardiac MRI, or catheter angiography) AND B. Patient is clinically stable AND C. Patient does not have any of the following: NYHA class IV heart failure; CABG or PCI within past 3 months; MI within past 40 days; clinical findings making them candidate for coronary revascularization; significant irreversible brain damage; non-cardiac disease with life expectancy < 1 year; poorly controlled supraventricular tachycardia such as atrial fibrillation with poorly controlled ventricular rateLVEF ≤ 0.30

Per NCD 20.4

Replacement ICD

Replacement of an existing ICD is considered reasonable and necessary when:

Replacement reasons: End of battery life, elective replacement indicator (ERI), or device/lead malfunction

Replacement per policy

The policy follows CMS NCD 20.8.3 and specifies explicit non‑covered indications for implanted permanent single‑ and dual‑chamber cardiac pacemakers. Per the NCD, pacemaker implantation is non‑covered for reversible causes of bradycardia (for example, electrolyte abnormalities, medication‑induced bradycardia, or hypothermia).

Additional enumerated non‑covered conditions include: asymptomatic first‑degree atrioventricular block; asymptomatic sinus bradycardia; asymptomatic sino‑atrial block or sinus arrest; ineffective atrial contractions (eg, chronic atrial fibrillation or giant left atrium) without symptomatic bradycardia; asymptomatic Mobitz Type I second‑degree AV block unless QRS prolonged or EP study shows block at/beyond the His bundle; syncope of undetermined cause; bradycardia during sleep; right bundle branch block with left axis deviation (and other fascicular or bundle branch block) without syncope or intermittent AV block symptoms; asymptomatic bradycardia in post‑MI patients awaiting beta‑blocker therapy; frequent or persistent supraventricular tachycardias except when the pacemaker is specifically for tachycardia control; and clinical conditions in which pacing is only intermittent and unlikely to become prolonged.

Services for permanent single‑ or dual‑chamber pacemakers and for ICDs addressed in this policy are considered not reasonable and necessary (non‑covered) when the specific CMS NCD criteria are not met. If the documented clinical presentation does not fulfill the NCD indications (for example, absence of documented non‑reversible symptomatic bradycardia for pacemakers), the procedure is non‑covered.

The policy explicitly states that when the NCD criteria are not satisfied, the related device implantation or service must be treated as not reasonable and necessary and may be denied.

Procedure, CPT/HCPCS, and Related Codes

Procedure and CPT codes listedCPT

0695T	BDY SURF ACTIVATION MAPG PM/CVDFB LEADS TM IMPLT
0696T	BDY SURF ACTIVATION MAPG PM/CVDFB LEADS TM F/UP
0795T	TCAT INSJ PERM DUAL CHAMBER LDLS PM COMPL SYS
0796T	TCAT INSJ PERM 2CHMBR LDLS PM R ATR PM COMPNT
0797T	TCAT INSJ PERM 2CHMBR LDLS PM R VENTR PM COMPNT
0798T	TCAT RMVL PERM DUAL CHAMBER LDLS PM COMPL SYS
0799T	TCAT RMVL PERM 2CHMBR LDLS PM R ATR PM COMPNT
0800T	TCAT RMVL PERM 2CHMBR LDLS PM R VENTR PM COMPNT
0801T	TCAT RMVL&RPLCMT PERM 2CHMBR LDLS PM 2CHMBR SYS
0802T	TCAT RMVL&RPLCMT PERM 2CHMBR LDLS PM R ATR CMPNT

1–10 of 26

1/3

Listed CPT/Temporary codes (partial)CPT

0824T	TCAT RMVL PERM 1CHMBR LDLS PACEMAKER R ATRIAL
0825T	TCAT RMVL&RPLCMT PERM 1CHMBR LDLS PM R ATRIAL
0826T	PRGRMG DEV EVAL LDLS PM SINGLE CAR CHAMBER IP
33202	INSERTION EPICARDIAL ELECTRODE OPEN
33203	INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC

Covered CPT Codes (continued)CPTCovered

33206	INS NEW/RPLCMT PRM PACEMAKR W/TRANS ELTRD ATRIAL
33207	INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR
33208	INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIAL&VENT
33210	INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH
33211	INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX
33212	INS PM PLS GEN W/EXIST SINGLE LEAD
33213	INS PACEMAKER PULSE GEN ONLY W/EXIST DUAL LEADS
33214	UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS
33215	RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE
33216	INSJ 1 TRANSVNS ELTRD PERM PACEMAKER/IMPLTBL DFB

1–10 of 35

1/4

Device programming and interrogation CPT codesCPTCovered

33271	INSJ OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE
33272	RMVL OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE
33273	REPOS PREVIOUSLY IMPLANTED SUBQ IMPLANTABLE DFB
33274	TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG
33275	TCAT REMOVAL PERM LEADLESS PM RIGHT VENTR W/IMG
93279	PRGRMG DEV EVAL 1 LEAD PM/LDLS PM 1 CAR CHMBR IP
93280	PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER
93281	PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER
93286	PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON
93288	INTERROG DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON

1–10 of 12

1/2

HCPCS/Codes for devices and suppliesHCPCSCovered

C1605	Pmkr, dual, leadless
C1721	Aicd, dual chamber
C1777	Lead, aicd, endo single coil
C1779	Lead, pmkr, transvenous vdd
C1785	Pmkr, dual, rate-resp
C1786	Pmkr, single, rate-resp
C1898	Lead, pmkr, other than trans
C2619	Pmkr, dual, non rate-resp
C2620	Pmkr, single, non rate-resp
C2621	Pmkr, other than sing/dual

1–10 of 14

1/2

Left ventricular ejection fraction thresholds — ICD indications

Post-myocardial infarction (post-MI)Left ventricular ejection fraction ≤ 0.30 measured by echocardiography, radionuclide imaging, cardiac MRI, or catheter angiography

Ischemic dilated cardiomyopathy (primary prevention)Left ventricular ejection fraction ≤ 35% measured by accepted modalities; patient clinically stable and NYHA class II or III

Non-ischemic dilated cardiomyopathy (primary prevention)Left ventricular ejection fraction ≤ 35%; patient on optimal medical therapy ≥ 3 months, clinically stable, NYHA class II or III

Remote interrogation reporting window

Remote interrogation windowInterrogation device evaluation (remote) reporting window: up to 90 days

Provider Requirements, Preauthorization, and Documentation

Prior Authorization

Preauthorization required for pacemaker/ICD procedures

Preauthorization is required for permanent cardiac pacemaker and related device procedures listed in this policy.

Prior Authorization

Preauthorization required for listed CPT/HCPCS codes

Preauthorization is required for the specific permanent pacemaker, leadless pacemaker, and implantable defibrillator procedure and device codes enumerated in the policy when requesting coverage.

Step Therapy

Step therapy not specified

Not applicable or not specified in this section of the document.

Background

A permanent cardiac pacemaker is a self‑contained, battery‑operated implanted device that delivers electrical stimulation to one or more cardiac chambers via implanted leads to treat symptomatic, non‑reversible bradyarrhythmias. The primary clinical purpose is to maintain adequate heart rate and atrioventricular synchrony in patients with documented symptomatic sinus node dysfunction or second‑ or third‑degree atrioventricular block.

Implantable cardioverter defibrillators (ICDs), which are also addressed in this policy under NCD 20.4, are battery‑powered implanted devices connected to the heart with leads that continuously monitor rhythm and automatically deliver therapies (anti‑tachycardia pacing or high‑energy shocks) to terminate life‑threatening ventricular tachyarrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF).

Definitions

Permanent cardiac pacemaker — definition and key attributes

DefinitionA self-contained, battery-operated implanted device that sends electrical stimulation to the heart through one or more implanted leads; classified by number of chambers stimulated (single- or dual-chamber)

Primary useTreatment of non-reversible symptomatic bradycardia due to sinus node dysfunction or second-/third-degree atrioventricular block

Implantation detailsInserted via catheter with leads threaded to appropriate chamber(s); pulse generator placed in a subcutaneous pocket in the upper chest

Typical settingProcedure performed under local anesthesia with brief hospitalization

Implantable cardioverter defibrillator (ICD) — definition and key attributes

Definition

Policy Revision History

05-20-2026policy_update

MCG (Milliman Healthcare Guidelines) criteria will be utilized in addition to CMS guidelines beginning 06/01/2026.

05-14-2026coding_updateLatest

Additional CPT/HCPCS codes were added to this policy effective 06/01/2026.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Permanent Cardiac Pacemakers (Preauthorization Required)

Policy CodePolicy M.30

Change TypeMaterial updates — codes addedMCG criteria added

Effective DateJan 1, 2026

Next Review DateAug 5, 2026

Key ActionObtain preauthorization for the listed permanent pacemaker and implantable defibrillator procedures using the policy's specified codes.

SourceLink

On This Page

Ischemic dilated cardiomyopathy primary prevention: A. Severe ischemic dilated cardiomyopathy with no personal history of sustained VT or cardiac arrest due to VF AND B. NYHA Class II or III heart failure AND C. Left ventricular ejection fraction ≤ 35% (measured by acceptable modalities) AND D. Patient is clinically stable AND E. Patient has none of the exclusion conditions: CABG or PCI within past 3 months; MI within past 40 days; clinical findings making them candidate for coronary revascularization; significant irreversible brain damage; non-cardiac disease with life expectancy <1 year; poorly controlled supraventricular tachycardiaLVEF ≤ 35%

Non-ischemic dilated cardiomyopathy primary prevention: A. Severe non-ischemic dilated cardiomyopathy with no personal history of sustained VT or cardiac arrest due to VF AND B. NYHA Class II or III heart failure AND C. Left ventricular ejection fraction ≤ 35% (measured by acceptable modalities) AND D. Patient has been on optimal medical therapy for at least 3 months AND E. Patient is clinically stable AND F. Patient has none of the exclusion conditions: CABG or PCI within past 3 months; MI within past 40 days; clinical findings making them candidate for coronary revascularization; significant irreversible brain damage; non-cardiac disease with life expectancy <1 year; poorly controlled supraventricular tachycardiaLVEF ≤ 35%; optimal medical therapy ≥ 3 months

Per NCD 20.4

Familial/genetic disorders: A. Documented familial or genetic disorders with high risk of life-threatening tachyarrhythmias (eg long QT syndrome, hypertrophic cardiomyopathy) AND B. Patient is clinically stable AND C. Patient does not have significant irreversible brain damage, non-cardiac disease with life expectancy <1 year, or poorly controlled supraventricular tachycardia

Per NCD 20.4

Physician review for remote interrogationRemote interrogation up to 90 days includes interim analysis, review(s) and report(s) by a physician or other qualified health care professional (per code 93294)

Technician review for remote dataRemote data acquisition with receipt of transmissions and technician review, technical support and distribution of results (per code 93296)

Note

MCG criteria to be used beginning 06/01/2026

Beginning 06/01/2026, Milliman Healthcare Guidelines (MCG) may be referenced and utilized in addition to CMS guidelines for utilization review decisions where applicable.

Documentation Required

Guideline use and contact for coverage criteria

Milliman Healthcare Guidelines (MCG) will be utilized when applicable; for login issues or requests for coverage criteria contact umanagement@p3hp.org.

MCG access: https://login.mcg.com (per policy link)
Contact email for coverage criteria or login problems: umanagement@p3hp.org

Documentation Required

Include listed CPT/HCPCS/device codes on preauthorization requests

When requesting preauthorization, include the policy’s listed CPT/HCPCS and HCPCS‑supplementary device codes; note additional codes were added effective 06/01/2026.

Refer to the Codes section for the full list of CPT and HCPCS codes enumerated in the policy (e.g., 0824T, 0825T, 0826T, 33202, 33203, etc.).
Operational note: Additional codes were incorporated effective 06/01/2026.

Denial Risk

Non‑covered services when NCD criteria not met

Services are not reasonable and necessary and therefore non‑covered when the specified NCD criteria are not met; the policy enumerates non‑covered indications for pacemakers per NCD 20.8.3.

Examples of non‑covered indications include reversible causes of bradycardia, asymptomatic conduction abnormalities, syncope of undetermined cause, bradycardia during sleep, and other conditions listed under NCD 20.8.3.

Denial Risk

Denial risk for missing preauthorization

Failure to obtain the required preauthorization for the procedures and codes listed in this policy may result in denial of coverage.

A battery-powered implanted device connected to the heart with leads that continuously monitors heart rhythms and automatically delivers therapies (electrical shocks, pacing pulses, or anti-tachycardia pacing) to correct life‑threatening ventricular arrhythmias such as ventricular tachycardia (VT) and ventricular fibrillation (VF)

Indications (examples)Personal history of sustained VT or cardiac arrest due to VF; primary prevention for post-MI LVEF ≤ 0.30 or for ischemic/non-ischemic cardiomyopathy with LVEF ≤ 35% when other criteria met (per NCD 20.4)

ReplacementReplacement ICD considered reasonable and necessary for end of battery life, elective replacement indicator (ERI), or device/lead malfunction

Programming device evaluation (in person) — definition/notes

DefinitionProgramming device evaluation (in person): iterative adjustment of the implantable device to test function and select optimal programmed values with analysis, review and report by a physician or other qualified health care professional

Applicable CPT examplesCodes include 0826T, 93279, 93280, 93281, 93286 corresponding to in-person programming/device evaluation for single-, dual-, or multi-lead and leadless systems

Use casesPerformed peri‑procedurally or during follow-up to validate device performance and program therapeutic parameters

Interrogation device evaluation (remote/in person) — notes

DefinitionInterrogation device evaluation (remote or in person): connection, recording, and analysis of device data with review and report by a physician or qualified health care professional; remote evaluations allowed up to 90 days

Remote technician reviewRemote data acquisition with receipt of transmissions, technician review, technical support and distribution of results (per code 93296)

Physician/qualified provider analysisRemote interrogation up to 90 days may include interim analysis, review(s) and report(s) by a physician or other qualified health care professional (per code 93294)