Benefits for a particular service or item are subject to the terms and conditions of the member's applicable benefit contract. These Medical Policies do not themselves constitute authorization, certification, or a contract for benefits; specific exclusions and limitations depend on the language of the member’s contract and any applicable plan provisions. The Medical Policy Committee’s evidence review and policy language guide coverage determinations, but benefit payment is ultimately governed by the member’s contract.

Determinations of scientific validity and medical necessity are made by the BCBSN Medical Policy Committee based on evidence review; these Medical Policies are used by the plan to administer benefits and do not constitute medical advice or automatic authorization. Services described in this policy are not automatically covered—preauthorization and review against the referenced criteria (including NCD 20.36 and InterQual clinical criteria) are required, and the Committee may update policy positions as new evidence emerges. Members and providers may follow the plan’s appeal processes when coverage or medical necessity determinations are adverse to the member.

Heart failure is a chronic condition in which the heart cannot meet metabolic demands, leading to fluid retention and increased intravascular volume. Progressive fluid accumulation can cause rising pulmonary artery pressures and pulmonary congestion that frequently precede symptomatic deterioration and can lead to acute decompensated heart failure (ADHF) and hospitalization. Implantable pulmonary artery pressure sensors (IPAPS) are devices implanted in the pulmonary circulation that measure PA pressures and transmit data to an external home monitoring unit for clinician review and management. Because pulmonary artery pressures often increase before clinical symptoms, remote hemodynamic monitoring with an implanted sensor can enable earlier clinician intervention to prevent exacerbations and reduce hospital admissions.