RetiredCapital BluecrossPolicy MP 2.007

CARDIAC INTERVENTION THERAPY FOR THE TREATMENT OF HEART FAILURE

Defines medical necessity and investigational indications for biventricular pacemakers/CRT with or without implantable cardioverter-defibrillator (CRT-D) for treatment of heart failure, product variations, policy guidelines, background, evidence summary, and coding guidance. Applies to Capital Blue Cross programs with benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyCARDIAC INTERVENTION THERAPY FOR THE TREATMENT OF HEART FAILURE

Policy CodePolicy MP 2.007

Change TypeRetirement / Delegation

Effective DateRETIRED 4/1/2025

Next Review Date

Key ActionProvider must document NYHA class, LVEF, cardiac rhythm, QRS duration/morphology, and that the patient is treated with guideline-directed medical therapy to support medical necessity; follow delegated entity processes for prior authorization and coverage determination as of 01/24/2025.

POLICY UPDATE CHANGES

01/24/2025 Retirement Review: Cardiac services will be delegated to TurningPoint.

12/11/2024 Administrative Update added codes 0915T-0929T effective 1/1/2025.

06/07/2024 Consensus Review: No change to policy statement. Background and Definitions updated. References added.

09/22/2020 Consensus Review: No change to policy statement. FEP language revised. Background, Rationale and References updated. Removed codes 0674T - 0685T. Added 0418T.

06/14/2021 Minor Review: Policy statement updated to include Cardiac Contractility Modulation (CCM) Therapy. Policy Name Change. Codes added.

12/01/2021 Administrative Review: Added 0674T-0685T. Effective date 1/1/2022.

03/11/2022 Administrative Review: Added K1030. Effective date 4/1/2022.

08/03/2023 Consensus Review: No change to policy statement or intent.

03/16/2020 Consensus Review: Policy statement unchanged. References updated. Coding reviewed.

Coverage Summary

Scope: This policy (MP 2.007) defines medical necessity and investigational indications for biventricular pacemakers/ cardiac resynchronization therapy (CRT), with or without an implantable cardioverter-defibrillator (CRT-D), for treatment of heart failure and provides related product, guideline, evidence and coding guidance; it applies to Capital Blue Cross programs subject to benefit variations. Status: RETIRED (effective 4/1/2025). Subject: Cardiac resynchronization therapy (biventricular pacemakers/CRT) for heart failure. Overview/Background: CRT coordinates left and right ventricular pacing to improve hemodynamics and left ventricular ejection fraction (LVEF) in patients with heart failure and ventricular dyssynchrony. Evidence from randomized controlled trials and meta-analyses supports CRT benefit primarily in patients with left bundle branch block or wide QRS duration (often ≥150 ms) and reduced LVEF. Device types include standalone CRT pacemakers (CRT-P) and combined CRT with defibrillator systems (CRT-D).

Policy thresholds

Left ventricular ejection fraction for NYHA III/IV≤ 35%

Left ventricular ejection fraction for NYHA II≤ 30%

QRS duration for NYHA III/IV conduction criterion alternative≥ 120 ms

QRS duration for NYHA II conduction criterion alternative≥ 150 ms

LV ejection fraction for alternative indication (AV block needing high % pacing)≤ 50%

PR interval threshold for AV block when paced at 100 bpm≥ 300 ms

policy_numberMP 2.007

policy_retired2025-04-01

Medically Necessary Criteria

Not Medically Necessary / Investigational Indications

Investigational device examples noted in the background include multisite/triple-site (triventricular) pacing, wireless left ventricular endocardial pacing (e.g., WiSE-CRT), intrathoracic fluid-monitoring sensors (CRT combined with OptiVol-type monitoring), and Cardiac Contractility Modulation (CCM). These specific technologies are listed in the policy's investigational/not medically necessary group and in the coding section as investigational/not covered procedures.

Coding

Investigational / not covered procedure codes (intrathoracic fluid-monitoring sensor; triple-site CRT; wireless LV endocardial pacing; CCM; synchronized diaphragmatic stimulation)CPT|HCPCS|C-code|OtherNot Covered

0408T
0409T
0410T
0411T
0412T
0413T
0414T
0415T
0416T
0417T

1–10 of 39

1/4

Covered when medically necessary procedure codesCPTCovered

33203
33207
33208
33213
33214
33217
33221
33224
33225
33228

1–10 of 17

1/2

Additional procedure and HCPCS/Codes listedHCPCS|CPT|Other

C1721
C1895
C1899
C1900
C2619
G0448

Relevant diagnosis ICD-10 codes (heart failure)ICD-10

I11.0	Hypertensive heart disease with heart failure
I50.1	Left ventricular failure
I50.20	Unspecified systolic (congestive) heart failure
I50.21	Acute systolic (congestive) heart failure
I50.22	Chronic systolic (congestive) heart failure
I50.23	Acute on chronic systolic (congestive) heart failure
I50.30	Unspecified diastolic (congestive) heart failure
I50.31	Acute diastolic (congestive) heart failure
I50.32	Chronic diastolic (congestive) heart failure
I50.33	Acute on chronic diastolic (congestive) heart failure

1–10 of 23

1/3

Codes removed previously (from history)CPT|HCPCS|mixedNot Covered

0674T	Removed (historical note)
0685T	Removed (historical note)

Codes added (historical updates)CPT|HCPCS|mixed

0418T	Added (historical note)
K1030	Added (historical note)
0915T	Added effective 1/1/2025 (administrative update)
0929T	Added effective 1/1/2025 (administrative update)

Effective-date guidance: the revision history documents administrative coding additions with effective dates (for example, codes added effective 1/1/2022, 4/1/2022, and 1/1/2025). Providers should bill using the procedure and HCPCS/CPT codes that are valid on the date of service and follow the policy/delegated-entity processes for prior authorization and coverage determination.

Provider Actions & Administrative Requirements

Documentation Required

Document NYHA class, LVEF, rhythm, QRS and guideline-directed therapy

Provider must document NYHA functional class, left ventricular ejection fraction, cardiac rhythm (sinus or atrial fibrillation), QRS duration/morphology, and that the patient is treated with guideline-directed medical therapy to support medical necessity.

NYHA functional class
Left ventricular ejection fraction (LVEF)
Cardiac rhythm (sinus or atrial fibrillation)
QRS duration and morphology (e.g., LBBB)
Documentation patient is on guideline-directed medical therapy

Documentation Required

Document AV block and pacing requirement

Background and Evidence Summary

CRT mechanism and device types: Cardiac resynchronization therapy paces the left and right ventricles synchronously to improve ventricular coordination, hemodynamics, and LVEF. Traditional CRT devices use three leads (right atrial, right ventricular endocardial, and left ventricular epicardial via the coronary sinus) and are available as standalone biventricular pacemakers (CRT-P) or combined with implantable cardioverter-defibrillators (CRT-D). Emerging/experimental technologies mentioned in the policy background — including multisite/triple-site pacing, multipolar/quadripolar leads, wireless left ventricular endocardial pacing, intrathoracic fluid-monitoring sensors, and CCM — are considered investigational and are listed in the investigational indications and coding sections.

Evidence summary

NYHA III/IV RCT evidenceConsistent RCTs show reduced mortality, improved functional status and QOL

NYHA II RCT evidenceMixed; hospitalization reductions consistent; mortality benefit in some trials/subgroups

NYHA I evidenceInsufficient; small samples and wide CIs

AV block with need for pacingRCT (BLOCK HF) shows reductions in HF hospitalizations with CRT vs RV pacing

Revision History

03/16/2020revised

03/16/2020 Consensus Review: Policy statement unchanged. References updated. Coding reviewed.

09/22/2020revised

09/22/2020 Consensus Review: No change to policy statement. FEP language revised. Background, Rationale and References updated. Removed codes 0674T - 0685T. Added 0418T.

06/14/2021revised (is_material=true)

06/14/2021 Minor Review: Policy statement updated to include Cardiac Contractility Modulation (CCM) Therapy. Policy Name Change. Codes added.

Policy Summary

PayerCapital Bluecross

PolicyCARDIAC INTERVENTION THERAPY FOR THE TREATMENT OF HEART FAILURE

Policy CodePolicy MP 2.007

Change TypeRetirement / Delegation

Effective DateRETIRED 4/1/2025

Next Review Date

On This Page

Billing Rule

Coding review and updates

Providers should note coding changes over time and bill using the codes valid for the service date. The policy history and coding sections list codes removed and added on specific dates (including additions effective 1/1/2022, 4/1/2022, and 1/1/2025); verify and use the code(s) applicable to the date of service when submitting claims.

0418T (added historically; noted 09/22/2020 entry)
K1030 (added effective 4/1/2022)
0674T-0685T (removed previously; historical notes and reinstatements)
0915T-0929T (added effective 1/1/2025)

Definitions / Glossary:

• High percentage ventricular pacing: presence of third-degree AV block; or second-degree AV block or a PR interval of ≥ 300 ms when paced at 100 beats per minute.

• Guideline-directed medical therapy: therapies per the 2022 AHA/ACC/HFSA heart failure management guidelines (Heidenreich et al. 2022).

• MP 2.007: internal cross-reference designation for Cardiac Intervention Therapy for the Treatment of Heart Failure.

• CCM (Cardiac Contractility Modulation): cardiac contractility modulation therapy (added to the policy on 06/14/2021) and considered investigational for heart failure in this policy.