ModifiedCignaPolicy 0174

Cardiac Resynchronization Therapy (CRT)

Defines medical necessity, replacement, and investigational status for biventricular pacemakers (with or without ICD) for cardiac resynchronization therapy and conduction system pacing; applies to Cigna-administered health benefit plans and providers submitting claims.

Policy Summary

PayerCigna

PolicyCardiac Resynchronization Therapy (CRT)

Policy CodePolicy 0174

Change TypeRevisions and additions to CRT and CSP statements

Effective DateJun 15, 2025

Next Review DateDec 15, 2025

Key ActionSubmit CRT device requests with covered diagnosis/procedure codes and documentation showing ≥3 months of optimal pharmacologic therapy and applicable clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

Revised policy statements for biventricular pacing.

Added policy statements for CRT for cardiomyopathy with persistent or permanent atrial fibrillation; and for conduction system pacing.

Revised statement for biventricular pacemaker for all other indications.

Remove leadless pacemaker from policy statement.

Removed wireless pacing CRT from policy statement.

Removed policy statement for body surface potential mapping.

Title changed from 'Cardiac Resynchronization Therapy (CRT) and Advanced Cardiac Pacing Technologies' to 'Cardiac Resynchronization Therapy (CRT)'.

≥150 msQRS duration favorable for CRT response

≤35%LVEF threshold cited

>40%RV pacing threshold prompting CRT consideration

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

33208,33224,33225,33249,33999

Common procedure codes discussed

9/1/2024Focused review date

2025-06-15Most recent annual review

Coverage Criteria for Cardiac Resynchronization Therapy (CRT)

Initial CRT eligibility

Covered when ALL of the following are met (individual has been on optimal pharmacologic regimen for ≥ 3 months):

Root: Individual has been on an optimal pharmacologic regimen for at least 3 months

Primary indications for ischemic or nonischemic cardiomyopathy in sinus rhythm: Ischemic or nonischemic cardiomyopathy, left ventricular ejection fraction (LVEF) ≤ 35%, sinus rhythm, and one of the following QRS/LBBB/NYHA combinations:LVEF ≤ 35%

Options: (1) QRS 120–149 ms AND LBBB AND NYHA Class II–ambulatory IV; (2) QRS ≥ 150 ms AND LBBB AND NYHA Class I–ambulatory IV; (3) QRS ≥ 150 ms AND non-LBBB AND NYHA Class III–ambulatory IVQRS 120–149 ms; QRS ≥ 150 ms

Atrial fibrillation indication: Ischemic or nonischemic cardiomyopathy with persistent or permanent atrial fibrillation AND LVEF ≤ 35% AND LBBB AND QRS ≥ 150 msLVEF ≤ 35%; QRS ≥ 150 ms

Anticipated RV pacing indication: Pre-existing or anticipated right ventricular (RV) pacing with a clinical indication for pacemaker/ICD implantation AND anticipated RV pacing > 40% AND intrinsic narrow QRS AND LVEF ≤ 35% AND NYHA Class I–ambulatory IV> 40% anticipated RV pacing; LVEF ≤ 35%

Conduction system pacing (HBP or LBBAP) for CRT

Covered when BOTH of the following are met:

Root: Individual meets one of the indications for biventricular pacing (see Initial CRT eligibility)

Secondary conditions: Either coronary sinus/left ventricular (CS/LV) lead placement was attempted and unsuccessful OR individual has LBBB and effective CRT cannot be achieved with a CS/LV lead

Replacement

Device generator replacement

Replacement indication: Replacement of a biventricular pacemaker generator alone or in combination with an implantable cardioverter defibrillator and/or leads is considered medically necessary

Includes battery end‑of‑life, malfunction, damage, or lead issues

Coverage criteria — patient selection and expected benefit

Evidence-supported patient selection considerations for CRT

Core indication: Heart failure with reduced ejection fraction (reduced LVEF) and evidence of ventricular conduction delay (especially LBBB) with wide QRS; CRT is most effective in patients with QRS ≥ 150 ms and LBBB morphology.QRS ≥ 150 ms favored

Multiple meta-analyses and studies demonstrate significant reduction in death or HF hospitalization for QRS ≥ 150 ms; LBBB morphology adds benefit.

Scenarios of limited or no benefit: QRS < 120 ms (narrow) shows no benefit and potential harm; QRS 120–149 ms shows inconsistent benefit with no significant pooled reduction in some analyses.QRS < 120 ms or 120–149 ms

LESSER‑EARTH and meta-analyses report lack of benefit for narrow/moderately prolonged QRS.

Patients requiring high ventricular pacing: Individuals with low LVEF receiving a new or replacement device who require ≥ 40% ventricular pacing may be appropriate for pacing therapy (CRT/physiologic pacing).

Coverage criteria — conduction system pacing

When conduction system pacing may be appropriate

CSP as alternative: Conduction system pacing (His bundle pacing or left bundle branch area pacing) may be clinically appropriate when conventional biventricular pacing is indicated but coronary sinus/LV lead placement was unsuccessful or ineffective, or in selected LBBB cases where conventional CRT cannot achieve resynchronization.

Evidence includes randomized and observational studies showing improvements in QRS duration and echocardiographic measures, though evidence is less robust than for conventional BiV CRT.

CSP technical and safety considerations: Providers should consider implantation success rates, higher capture thresholds (particularly with HBP), risk of lead complications (dislodgement, septal/RBB injury), longer procedure times, and operator experience when selecting CSP.

Randomized and observational studies report variable success and complication rates; FDA lead approvals expanded for His/LBB area pacing; long‑term lead survival data are limited.

CRT (BiV) primary indications

Guideline‑based CRT indications (selected high‑certainty recommendations):

Class I CRT indication: Patients with LVEF ≤ 35%, sinus rhythm, LBBB with QRS ≥ 150 ms, and NYHA class II–IV symptoms on guideline‑directed medical therapy — CRT with biventricular pacing is indicated to improve symptoms and reduce morbidity and mortality.LVEF ≤ 35%; QRS ≥ 150 ms

Class I; Level A/B-R depending on guideline

Class I (select) CRT indication: In selected patients (e.g., females) with LVEF ≤ 35%, sinus rhythm, LBBB and QRS 120–149 ms with NYHA II–IV on GDMT, CRT with BiV pacing is recommended to reduce mortality and HF events and to improve LVEF.QRS 120–149 ms

Class I or strong recommendation in select subgroups per guidelines

Conduction system pacing (CSP) considerations

Recommendations where conduction system pacing (CSP) may be reasonable:

CSP for anticipated substantial RV pacing: For patients with an indication for permanent pacing and anticipated substantial ventricular pacing (eg, >40%) with LVEF 36%–50%, cardiac physiologic pacing (CSP/CPP) is reasonable to reduce the risk of pacing‑induced cardiomyopathy.LVEF 36%–50%; >40% anticipated pacing

Class IIa; Level B‑R/B‑NR depending on statement

CSP for failed CRT or CRT nonresponder: CSP may be considered in patients with failed coronary sinus/LV lead implantation or CRT nonresponders with LBBB and reduced LVEF as an alternative strategy to achieve resynchronization.LVEF ≤ 35% (or 36–50% in some statements)

Class IIa in guideline statements; evidence base smaller than for BiV CRT

Multi‑lead/triventricular CRT (TriV) stance

Evidence summary and stance on multi‑lead/triventricular pacing:

Multi‑lead/Triple‑site CRT evidence: Randomized trials and meta‑analyses have not demonstrated consistent clinical benefit of multi‑lead (TriV) pacing over conventional BiV CRT; some studies show limited improvements in selected echocardiographic or quality‑of‑life measures but no consistent differences in functional capacity, HF hospitalization, or mortality.

Meta-analyses and RCTs show heterogeneity, small samples, and mixed results

Practical downsides of TriV: TriV/triple‑site pacing is associated with longer procedure times, higher pacing thresholds, reduced battery longevity, and potential procedural complications; evidence is insufficient to support routine use.

Clinical and technical disadvantages noted in trials (e.g., STRIVE HF) and meta-analyses

CRT coverage criteria by guideline class

Covered when guideline criteria are met according to Class/LOE statements:

Class I CRT indication (strong): Patients with LVEF ≤ 35%, sinus rhythm, LBBB with QRS duration ≥ 150 ms, and NYHA class II–IV symptoms on guideline‑directed medical therapy (GDMT)LVEF ≤ 35%; QRS ≥ 150 ms; NYHA II–IV

Class I; Level B‑R/A depending on guideline

Class IIa (reasonable/useful) CRT indications: Includes: LVEF ≤ 35% with LBBB and QRS 120–149 ms; non‑LBBB with QRS ≥ 150 ms; patients with anticipated significant (>40%) ventricular pacing (eg, LVEF ≤ 35% undergoing device implantation) or AVJ ablation to ensure near‑100% biventricular pacing; patients with AV block and LVEF 36–50% expected to require >40% pacing where physiologic pacing/CRT is reasonable.QRS 120–149 ms (selected); >40% pacing; LVEF 36–50%

Class IIa; Level B‑R / B‑NR depending on indication

Class IIb (may be considered):

Coding and medical necessity linkage

Codes considered medically necessary when applicable policy criteria are met

Medically necessary coding conditions: Use the listed CPT codes (33208, 33224, 33225, 33249) to report insertion or replacement of a biventricular pacemaker alone or combined with an ICD and/or leads when the policy's clinical criteria are satisfied. For conduction system pacing, unlisted procedure code 33999 may be used; note that triplesite/triventricular pacing billed with 33999 is considered Experimental/Investigational/Unproven.

Code list may not be all‑inclusive; confirm current code status at time of service.

Use of a biventricular pacemaker (with or without an implantable cardioverter defibrillator) for any indication other than those specified in this Coverage Policy is considered not medically necessary.

Triple-site or triventricular (TriV) pacing CRT is considered experimental, investigational, or unproven for any indication. Randomized trials and meta-analyses have not demonstrated consistent clinical benefit of multi‑lead/triventricular pacing over conventional biventricular CRT, and TriV approaches have been associated with longer procedure times, higher pacing thresholds, and reduced battery longevity.

CRT for patients with a narrow QRS (<120 ms) is not supported by randomized trial evidence and, in at least one trial (LESSER-EARTH), was associated with potential harm. Available randomized and pooled trial data do not demonstrate consistent patient‑level benefit for CRT in narrow QRS patients and therefore CRT is not indicated outside of research settings for this population.

There is a paucity of evidence supporting the long‑term safety and efficacy of triple‑site resynchronization compared with conventional biventricular pacing. Small trials and meta-analyses report heterogeneous results with limited follow‑up and small sample sizes, limiting conclusions about durable clinical benefit.

CRT is not recommended for patients with NYHA class I or II symptoms who have a non‑LBBB pattern with QRS duration <150 ms (Class III: No Benefit). CRT is also not indicated in patients whose comorbidities or frailty limit expected survival with good functional capacity to less than 1 year.

Triplesite or triventricular pacing CRT reported using CPT code 33999 (unlisted procedure, cardiac surgery) is considered Experimental/Investigational/Unproven when used to report this triplesite/triventricular pacing approach.

Policy revision details document that wireless pacing CRT and leadless pacemaker approaches were removed from the policy statements during recent reviews; these technologies are no longer included in the active policy statements.

CRT for patients with a narrow QRS (<120 ms) has not demonstrated benefit in randomized trials and was associated with potential harm in at least one trial (LESSER-EARTH). Consequently, CRT is not supported for routine use in patients with QRS <120 ms.

Use of CRT in heart failure patients with narrow QRS complexes (<120 ms), and in many patients with QRS 120–149 ms, lacks demonstrated clinical benefit in pooled randomized data; benefit is most consistently observed in patients with QRS ≥150 ms, particularly with LBBB morphology.

Routine use of multi‑lead or triventricular pacing for CRT recipients is not supported due to lack of consistent evidence of clinical benefit and concerns about procedural complexity, higher pacing thresholds, and reduced device longevity.

A Class III (No Benefit) statement applies to certain subgroups: for example, patients with NYHA class I or II symptoms and a non‑LBBB pattern with QRS <150 ms should not receive CRT; CRT is also not indicated for patients with limited life expectancy (<1 year) where benefit is unlikely.

FDA device product codes for biventricular devices include NKE (CRT‑P) and NIK (CRT‑D); these devices have been approved via the PMA process and are classified as FDA Class III devices.

Coding and Billing for CRT Devices

Billing Rule

Coding currency and eligibility

This list of codes may not be all-inclusive since the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) code updates may occur more frequently than policy updates. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.

Prior Authorization

Device implantation coding requirements

Considered Medically Necessary when criteria in the applicable policy statements listed above are met and when used to report the insertion or replacement of a biventricular pacemaker alone or when combined with an implantable cardioverter defibrillator (ICD) and/or leads. Prior authorization/coverage applies when criteria in the policy statements are met and these CPT codes are used to report insertion or replacement.

Provider action: Procedure reporting — use the CPT codes below to report insertion or replacement of biventricular pacemaker (CRT-P) and CRT-D devices when policy criteria are met.

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization and coverage determination

Coverage determinations require review of the applicable benefit plan, applicable laws/regulations, collateral materials, and the specific facts of the case; devices should be submitted with covered diagnosis/procedure codes and meet the policy's medical necessity criteria.

Each coverage request is reviewed on its own merits and reimbursement is only provided when services are submitted in accordance with relevant policy criteria and covered codes.
Medical directors have discretion to exercise clinical judgment in individual determinations.

Prior Authorization

Prior authorization consideration: QRS duration and morphology

Prior authorization should consider QRS duration and morphology: CRT is most beneficial for individuals with intrinsic QRS ≥ 150 ms and LBBB; evidence does not support benefit for many patients with QRS < 150 ms (particularly 120–149 ms) or < 120 ms.

Pooled analyses show a significant benefit for QRS ≥ 150 ms but no significant benefit for QRS < 150 ms.
LESSER‑EARTH and other trials found no benefit and potential harm with QRS < 120 ms.

Background and Evidence Summary

Heart failure with reduced ejection fraction can produce ventricular dyssynchrony manifested as a wide QRS and worsened pump function. Cardiac resynchronization therapy (CRT), most commonly delivered via biventricular pacing, aims to restore coordinated ventricular contraction to improve symptoms, functional status, and some clinical outcomes in selected patients who remain symptomatic despite optimized medical therapy.

inv-72: Guidelines cited — Major professional guidelines and guidance documents referenced include ACC/AHA/HRS, ESC, AHA/ACC management guidelines, and NICE technology appraisals.

Guideline sourcesACC/AHA/HRS and related society guidelines cited in references

European guidanceEuropean Society of Cardiology (ESC) documents referenced

Other guidanceNICE technology appraisals and AHA/ACC management guidelines referenced

inv-73: Key evidence sources — References cited include randomized trials, meta-analyses, systematic reviews, and professional guidelines relevant to CRT, His-bundle pacing, and LBBP.

Definitions and Key Terms

inv-63: Cardiac resynchronization therapy (CRT) — Definition summary

Summary definitionCardiac resynchronization therapy (CRT) is a pacing approach, commonly biventricular pacing, to improve coordination of ventricular contraction and LV function.

Typical leadsUsually involves right atrial, right ventricular, and coronary sinus/left ventricular leads

Clinical goalImprove NYHA class, symptoms, and some clinical outcomes in selected patients on optimal medical therapy

inv-64: CRT-D — CRT combined with ICD definition

DefinitionCRT-D combines CRT pacing with an implantable cardioverter‑defibrillator to treat both dyssynchrony and life‑threatening ventricular arrhythmias.

Indication linkage

Policy Revision History

2025-06-15Annual Review - Title and policy additions/revisionsLatest

Annual review updated the policy title to 'Cardiac Resynchronization Therapy (CRT)', revised policy statements for biventricular pacing, and added statements for CRT in cardiomyopathy with persistent or permanent atrial fibrillation and for conduction system pacing; wireless pacing CRT was removed from the policy statements.

2024-09-01Focused Review - Removal

Focused review removed leadless pacemaker from the policy statement.

2024-01-15Annual Review - Revision and removal

Policy Summary

PayerCigna

PolicyCardiac Resynchronization Therapy (CRT)

Policy CodePolicy 0174

Change TypeRevisions and additions to CRT and CSP statements

Effective DateJun 15, 2025

Next Review DateDec 15, 2025

Key ActionSubmit CRT device requests with covered diagnosis/procedure codes and documentation showing ≥3 months of optimal pharmacologic therapy and applicable clinical criteria are met.

SourceLink

On This Page

>= 40% ventricular pacing

Supported in literature review and guideline statements.

Atrial fibrillation considerations: CRT can be considered in patients with persistent/permanent atrial fibrillation and reduced EF when rate control or AV nodal ablation will allow near 100% ventricular pacing and other CRT criteria are met.near 100% ventricular pacing

Evidence and guideline discussion support use in selected AF patients when pacing can be assured.

Selected patients (various subgroups) where benefit is less certain; individualized decision making recommended.

Class IIb; Level B/C evidence

Not recommended (Class III): Patients with QRS duration below guideline thresholds (eg, <120–130 ms depending on guideline) or NYHA I–II with non‑LBBB and QRS <150 ms; patients with limited life expectancy <1 year where CRT/CRT‑D would not be appropriate.QRS <120–130 ms; survival <1 year

Class III; Level A/B/C depending on guideline

Provider action: No prior authorization statements are present beyond the note that prior authorization/coverage applies when the policy criteria are met and the CPT codes are used.

Provider action: No denial triggers present in this reference beyond standard coding currency and eligibility cautions.

Provider action: No documentation requirements are specified in this section.

Provider action: No step therapy requirements appear in this section.

Covered CPT Codes for Biventricular/CRT device insertion or replacementCPTCovered

33208	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
33224	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)
33225	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)
33249	Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

Conduction system pacing codingCPT

33999

Unlisted procedure, cardiac surgery — may be used to report conduction system pacing (e.g., His bundle pacing, left bundle branch area pacing). Note: Considered Experimental/Investigational/Unproven when used to report triplesite or triventricular pacing CRT

Documentation Required

Prior authorization — conduction system pacing

Unlisted cardiac surgery procedure code 33999 may be used to report conduction system pacing; note that triplesite/triventricular pacing reported with 33999 is considered Experimental/Investigational/Unproven.

Provider action: Procedure reporting — when using unlisted code 33999 include operative report and justification to support the use of an unlisted procedure code.
Provider action: Coding currency — confirm codes are effective at date of service to avoid claim denials.

Prior Authorization

Prior authorization — common CRT device codes

Considered Medically Necessary when criteria in the applicable policy statements listed above are met and when used to report conduction system pacing.

Prior Authorization

CRT (BiV) indications and device recommendations

CRT with biventricular pacing is indicated for patients with LVEF ≤ 35%, sinus rhythm, LBBB and QRS ≥ 150 ms (Class I); quadripolar LV leads are recommended to assist lead stability and lower thresholds.

Class I indication: LVEF ≤ 35%, sinus rhythm, LBBB, QRS ≥ 150 ms, NYHA II–IV on GDMT.
Quadripolar LV lead recommendation noted to improve lead stability and thresholds.

Prior Authorization

Device implantation coding requirements

Prior authorization/coverage applies when the policy criteria are met and these CPT codes are used to report insertion or replacement of biventricular pacemakers, LV pacing leads, ICD systems, or unlisted cardiac procedures for conduction system pacing.

Codes referenced include 33208, 33224, 33225, 33249, and 33999 per the policy's Coding section.

Prior Authorization

Prior authorization — common CRT device codes

These CPT codes are considered medically necessary when the applicable policy clinical criteria are met and are used to report insertion or replacement of a biventricular pacemaker alone or with an ICD and/or leads.

33208, 33224, 33225, and 33249 are listed as considered medically necessary when policy criteria are satisfied.

Prior Authorization

Prior authorization — conduction system pacing

Unlisted cardiac surgery procedure code 33999 may be used to report conduction system pacing; the policy also states that triplesite/triventricular pacing billed with 33999 is considered experimental/investigational/unproven.

33999 — Unlisted procedure, cardiac surgery (used to report conduction system pacing).
If 33999 is used to bill triplesite/triventricular CRT, that use is considered Experimental/Investigational/Unproven.

Prior Authorization

Prior authorization aligned with revised CRT statements

Prior authorization requirements should follow the updated policy statements; the policy was revised to address biventricular pacing, CRT for persistent/permanent atrial fibrillation, and conduction system pacing.

Annual review dated 6/15/2025 revised policy statements and added CRT and conduction system pacing items.
Submit requests consistent with the revised coverage statements.

Step Therapy

Medical optimization prerequisite

Document that the individual has been on an optimal pharmacologic regimen for at least 3 months before consideration of implantation; this is a prerequisite for coverage.

All assessments (ECG, QRS, LVEF) should be performed after ≥3 months of optimized guideline‑directed medical therapy (GDMT).

Step Therapy

Preferred initial CRT approach

Conventional biventricular CRT is the established initial approach; conduction system pacing (His bundle or LBBAP) may be used as an alternative in select cases such as unsuccessful coronary sinus/LV lead placement or inability to achieve effective CRT.

CSP may be reasonable when CS/LV lead placement was attempted and unsuccessful or when effective CRT cannot be achieved with a CS/LV lead.

Step Therapy

Preferred sequencing of CRT vs conduction system pacing

Guidance prefers traditional biventricular CRT where evidence is stronger; conduction system pacing may be reasonable in select patients (e.g., anticipated substantial RV pacing or failed CS/LV lead), but the evidence base for CSP is less robust.

Multiple randomized controlled trials support CRT more strongly than the largely observational CSP evidence base.
CSP may be reasonable for anticipated substantial ventricular pacing or failed CRT attempts.

Step Therapy

GDMT optimization implied

Guideline-based sequencing implies optimization of guideline-directed medical therapy before CRT, though no explicit stepwise algorithm is provided in the excerpt.

Assessments and device consideration should occur after ≥3 months of GDMT per the professional society recommendations.

Documentation Required

Pre‑implant assessments — timing and accuracy

Pre-implant assessments (ECG for LBBB/RBBB/IVCD, QRS duration, and LVEF) should be accurate and performed after ≥3 months of optimized guideline‑directed medical therapy.

If persistent AF is present, CRT pacing should be maximized with a high percentage of pacing (≥98%) to optimize delivery.
Ensure measurement accuracy for QRS duration and LVEF prior to submission.

Documentation Required

Required procedural documentation

Procedural reports should document implant success, pre- and post‑procedure QRS duration, and confirmation of capture (for example, His or left bundle branch capture) and note any lead complications.

Document implant success rate, changes in QRS duration, capture confirmation, and any complications such as lead dislodgement or septal injury.
Record crossovers between pacing strategies if they occurred.

Documentation Required

Procedural documentation — leads and capture thresholds

Procedural notes should document lead type and location (e.g., His bundle vs coronary sinus LV lead), capture thresholds at implant and follow‑up, and any crossovers or complications.

Include capture thresholds, lead stability, and descriptions of any intraprocedural crossovers.
Record whether His or LBB capture was achieved and maintained.

Denial Risk

Coding/claim compliance — use covered codes

Services billed with diagnosis or procedure codes not listed as covered under this Coverage Policy will be denied as not covered.

Submit services only with covered diagnosis and procedure codes per the policy; unsupported codes can lead to denial.

Denial Risk

Denial risk when QRS <120 ms

CRT is unlikely to benefit individuals with narrow QRS (<120 ms); treatments outside established selection criteria (eg, narrow QRS) are at risk for denial and may be associated with potential harm.

LESSER‑EARTH and meta-analyses report no benefit and possible harm for QRS <120 ms.
Pooled analyses found no significant benefit for QRS <150 ms.

Denial Risk

Implant/capture failure risk — document successes and crossovers

High rates of intraprocedural crossover, inability to achieve capture, or lead placement failure have been reported (especially with His bundle pacing) and may result in lack of durable therapy; document implant success and capture to support continued coverage.

His‑CRT trials reported substantial crossover and higher implantation failure rates compared with BiV‑CRT (e.g., 72% vs 96% implantation success in one pilot trial).
Document any crossovers and reasons (high capture thresholds, inability to capture, anatomical issues).

Billing Rule

Coding currency and eligibility — verify code effectiveness

Claims may be denied if codes were deleted or not effective on the date of service; verify code currency before submission as the policy's code list may not be exhaustive.

Policy note: check AMA/CMS updates and Medicare LCD/NCD guidance for up-to-date code applicability.

Denial Risk

Coding currency and eligibility — deleted/inactive codes risk

Deleted CPT codes and codes not effective at the time of service may not be eligible for reimbursement; confirm active status of codes prior to claim submission.

Ensure codes used are active and effective on the service date to avoid denial.

Denial Risk

Denial risk for removed technologies

Removal of certain technologies (wireless pacing CRT, leadless pacemaker, body surface potential mapping) from the policy statements may result in non‑coverage or denial for those specific device approaches if submitted.

Focused review removed leadless pacemaker (9/1/2024) and wireless pacing CRT was removed from the policy statement.
If submitting claims for these removed technologies, expect potential non‑coverage.

Documentation Required

Claims and coding documentation — submit according to policy

Providers must submit services in accordance with the relevant criteria outlined in the Coverage Policy, including covered diagnosis and procedure codes and use the most appropriate codes as of the effective date of submission.

Claims submitted for services without covered codes under this policy will be denied as not covered.
Use current codes and confirm plan-specific coverage terms where applicable.

Billing Rule

Coding and Medicare reference — confirm coverage guidance

Use appropriate CPT/ICD codes for reporting insertion or replacement of biventricular pacemakers or ICDs and confirm Medicare LCD/NCD guidance for up‑to‑date coverage determinations.

Review local Medicare coverage (LCD) and national determinations (NCD) as they may affect reimbursement.
Follow the policy's listed CPT codes when clinical criteria are met.

Trial and meta-analysesRandomized trials and meta-analyses (e.g., MADIT-CRT, MIRACLE, AdaptResponse) cited

Systematic reviewsSystematic reviews and meta-analyses of CRT, His-bundle pacing, and LBBP included in references

Observational studies and registriesProspective registries and observational comparative studies supporting CSP and LBBP evidence base

inv-63: Cardiac resynchronization therapy (CRT) — Definition and common approach (biventricular pacing via coronary sinus/LV lead).

DefinitionCardiac resynchronization therapy (CRT) commonly refers to biventricular pacing that stimulates both ventricles via leads (including a coronary sinus/left ventricular lead) to improve ventricular coordination and LV function.

Typical approachMost commonly achieved with transvenous RV and coronary sinus LV lead placements connected to a biventricular pacemaker

PurposeAims to improve symptoms, functional class, and some clinical outcomes in selected HFrEF patients

inv-64: CRT-D — Definition (CRT combined with implantable cardioverter defibrillator).

DefinitionCRT-D denotes a cardiac resynchronization therapy system combined with an implantable cardioverter-defibrillator to provide both resynchronization and automatic correction of life-threatening ventricular arrhythmias.

Indication linkCRT-D may be used when patients meet both CRT pacing criteria and separate ICD indications

ReferencePolicy refers to separate ICD coverage policy for detailed ICD indications

inv-65: Conduction system pacing (CSP) — Definition (His bundle pacing or left bundle branch area pacing).

DefinitionConduction system pacing (CSP) encompasses His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) that target the native conduction system to mimic physiologic ventricular activation.

Use casesConsidered when conventional LV/CS lead placement is unsuccessful or ineffective, or in select scenarios to avoid RV pacing–induced cardiomyopathy

EvidenceSupported primarily by observational studies; ongoing randomized trials referenced

inv-66: QRS duration categories — narrow (<120 ms), moderately prolonged (120-149 ms), severely prolonged (≥150 ms).

NarrowNarrow QRS: < 120 ms

Moderately prolongedModerately prolonged QRS: 120–149 ms

Severely prolongedSeverely prolonged QRS: ≥ 150 ms

inv-67: Cardiac physiologic pacing (CPP) — Definition and intent to restore physiologic activation.

DefinitionCardiac physiologic pacing (CPP) describes pacing intended to restore or preserve physiologic ventricular synchrony, achieved via CSP or CRT techniques.

Intended effectAim is to reduce pacing-induced dyssynchrony and mitigate heart failure progression when substantial ventricular pacing is anticipated

IncludesIncludes His bundle pacing, left bundle branch area pacing, and biventricular pacing approaches

inv-68: Triventricular (TriV) pacing — Definition of multi-lead CRT configurations.

DefinitionTriventricular (TriV) pacing is a multi‑lead CRT configuration that adds an additional ventricular pacing lead (eg, via Y‑connector) to attempt improved resynchronization.

ConfigurationsTypical setups include two ventricular leads plus atrial and RV leads or alternative two‑RV + one‑LV configurations

Evidence stanceRandomized trials and meta-analyses have not demonstrated consistent clinical benefit over conventional BiV CRT

inv-69: Class of Recommendation / Level of Evidence — Explanation of Class I/IIa/IIb/III and evidence levels.

Class definitionsClass I: Recommended (Benefit >> Risk); Class IIa: Reasonable (Benefit > Risk); Class IIb: May be considered; Class III: No benefit or Harm.

Level of EvidenceLOE categories include Level A, B-R, B-NR, C-LD, and C-EO reflecting randomized data, nonrandomized studies, limited data, or expert opinion respectively.

UseClass/LOE used to align CRT and CSP recommendations in policy and referenced guidelines

inv-70: Conduction system pacing (CSP) — Additional definitional content and current evidence summary.

Definition and scopeCSP includes His bundle pacing and left bundle branch area pacing; current evidence is evolving with many observational studies and some pilot randomized trials.

Technical considerationsChallenges include higher capture thresholds (HBP), lead stability, and potential septal injury with LBBAP; FDA approvals exist for specific leads for HBP and LBB pacing.

Evidence summaryLong‑term lead survival and randomized comparative effectiveness data remain limited; ongoing trials are cited in references.

inv-71: Conduction system pacing / CRT — Procedural approaches to achieve CRT including transvenous LV pacing and CSP.

Procedural approachesCRT can be achieved via transvenous LV pacing (coronary sinus lead) for BiV pacing or via conduction system pacing (His/LBB) to attain resynchronization.

When CSP usedCSP is considered when CS/LV lead placement fails or effective CRT cannot be achieved with CS/LV lead

Documentation needsProcedural reports should document lead type/location (His vs CS/LV), capture thresholds, and any crossovers between pacing strategies

Used when patient meets CRT pacing criteria and separate ICD indications

DocumentationRefer to ICD policy for detailed ICD coverage conditions

inv-65: Conduction system pacing (CSP) — Definition (His or LBB area pacing)

DefinitionConduction system pacing (CSP) targets the native conduction system via His bundle or left bundle branch area pacing to mimic physiologic activation.

TechniquesIncludes His bundle pacing (HBP) and left bundle branch area pacing (LBBAP/LBBP)

Clinical roleOffered as an alternative when conventional CRT is unsuccessful or to avoid pacing‑induced cardiomyopathy in select patients

inv-66: QRS duration categories — narrow/moderately prolonged/severely prolonged cutoffs

CutoffsNarrow: <120 ms; Moderately prolonged: 120–149 ms; Severely prolonged: ≥150 ms

Clinical implicationGreatest CRT benefit observed with QRS ≥150 ms, especially with LBBB morphology

Limited benefitNarrow QRS (<120 ms) and many with 120–149 ms show inconsistent benefit

inv-67: Cardiac physiologic pacing (CPP) — Definition

DefinitionCardiac physiologic pacing (CPP) intends to restore or preserve synchronous ventricular contraction via CSP or CRT techniques.

IncludesHis bundle pacing, left bundle branch area pacing, and biventricular pacing approaches

GoalReduce risk of pacing‑induced cardiomyopathy when substantial ventricular pacing anticipated

inv-68: Triventricular (TriV) pacing — Definition

DefinitionTriventricular (TriV) pacing is a multi‑lead CRT configuration adding an extra ventricular lead (eg, Y‑connector) to attempt improved resynchronization.

EvidenceRandomized trials/meta-analyses have not shown consistent clinical benefit; practical downsides include longer procedure times and higher thresholds

Policy stanceTriV considered experimental/investigational/unproven for routine use

inv-69: Class of Recommendation / Level of Evidence — Definition

Class definitionsClass I: Benefit >> Risk (recommend); Class IIa: reasonable; Class IIb: may be considered; Class III: No benefit or harm.

Level definitionsLOE A, B-R, B-NR, C-LD, C-EO denote evidence quality from multiple RCTs to expert opinion

Use in policyClass/LOE statements used to map coverage criteria and recommendation strength

inv-70: Conduction system pacing (CSP) — Additional definition content

DefinitionConduction system pacing (CSP) includes His bundle and left bundle branch area pacing; evidence consists largely of observational data with growing trials.

Technical issuesIncludes higher HBP capture thresholds, potential lead complications, and variable implantation success rates

Regulatory noteFDA approvals expanded for SelectSecure 3830 lead for His and LBB area pacing

inv-71: Conduction system pacing / CRT — Procedural approaches definition

ApproachesCRT via transvenous LV (coronary sinus) lead or CSP (His/LBB) are procedural options to achieve resynchronization

When to use CSPCSP appropriate when CS/LV lead placement unsuccessful or effective CRT cannot be achieved with CS/LV lead

DocumentationProcedural reports should document lead type, capture confirmation, and any complications

inv-72: Guidelines cited — list of guideline sources referenced

Included guidelinesACC/AHA/HRS, ESC, AHA/ACC management guidelines cited in references

Other sourcesNICE technology appraisals and society-specific CPP guidance (HRS/APHRS/LAHRS) referenced

Recent yearsReferences include guideline publications up to 2024–2025

inv-73: Key evidence sources — list of primary evidence types cited

Randomized trialsMultiple RCTs cited (eg, MADIT-CRT, MIRACLE, AdaptResponse, HOPE-HF) supporting CRT evidence base

Meta-analyses and systematic reviewsMeta-analyses and systematic reviews evaluating QRS duration, morphology, and CRT outcomes are referenced

Observational studies and registriesObservational studies and registries inform CSP/LBBP evidence and are included in references

Annual review revised the statement for biventricular pacemaker for other indications and removed the policy statement for body surface potential mapping.

Policy revisions and removals are documented in the Revision Details (Annual and Focused Reviews), which record changes such as revised biventricular pacing statements, additions for CRT in persistent/permanent atrial fibrillation and conduction system pacing, and removals of wireless and leadless pacing approaches.