Colorado Rocky Mountain Health Plans cardiovascular policy update

Coverage Criteria and Application

inv-01: Coverage references and delegation

Where Medicare coverage guidance exists, follow that guidance; where it does not, the policy delegates to specified UnitedHealthcare or other internal policies for medical necessity rules.

Coverage references: Where Medicare has a National Coverage Determination (NCD), follow the NCD; where no NCD exists but Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist, compliance with those LCDs/LCAs is required; where no NCD/LCD/LCA exists, refer to the named UnitedHealthcare Medicare Advantage or Commercial Medical Policies (examples: Radiologic Diagnostic Procedures; Catheter Ablation for Atrial Fibrillation; Lower Extremity Endovascular Procedures; Transcatheter Procedures for Heart Valve Conditions; Cardiovascular Disease Risk Tests) for specific coverage criteria.

Directs readers to other UnitedHealthcare policies or CMS LCD/NCD materials for detailed medical necessity criteria.

inv-02: Implantable Pulmonary Artery Pressure Sensors (IPAPS)

CMS has issued a National Coverage Determination specific to implantable pulmonary artery pressure sensors.

IPAPS coverage under NCD 20.36: Implantable pulmonary artery pressure sensors (IPAPS) for heart failure management are not covered outside of a CMS‑approved study per NCD 20.36.

Coverage may still occur under NCD 310.1 (Clinical Trial Policy) or via an Investigational Device Exemption (IDE); consult the CMS CED clinical trials list for eligible studies.

inv-03: Lower Extremity Endovascular Revascularization Procedures

Medicare coverage distinctions for lower extremity endovascular revascularization procedures depend on presence of an NCD or local contractor guidance.

Lower extremity PTA: Medicare has an NCD (PTA 20.7) that covers percutaneous transluminal angioplasty (PTA) of the lower extremity arteries without stenting and/or atherectomy (iliac, femoral, popliteal). PTA with stenting and/or atherectomy does not have an NCD; where LCDs/LCAs exist, compliance with those local policies is required. For states/territories without LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Lower Extremity Endovascular Procedures for coverage guidance.

When no NCD or LCD/LCA applies, UnitedHealthcare commercial/MA policy criteria are used.

inv-04: Application of CMS coverage documents and internal criteria

Approach to applying CMS documents and internal criteria for coverage decisions.

Medicare-based coverage application: Coverage determinations begin with checking CMS materials (NCDs, LCDs, LCAs) and the Medicare Coverage Database; where CMS guidance exists, that guidance is followed. If no applicable NCD/LCD/LCA is found or CMS guidance allows flexibility beyond listed indications, UnitedHealthcare applies internal coverage criteria as described in this policy's Coverage Rationale.

This policy does not replace Medicare source materials; where conflicts exist, Medicare source materials govern. Internal criteria were developed from evaluation of clinical evidence and guidelines.

Per CMS NCD 20.36, implantable pulmonary artery pressure sensors (IPAPS) for heart failure management are not covered outside of a CMS‑approved study. The NCD effective date is noted in the CMS guidance; coverage may still be possible under an approved CMS Coverage with Evidence Development (CED) clinical trial or via NCD 310.1 (Clinical Trial Policy) or an Investigational Device Exemption (IDE). Providers should refer to the CMS CED trial list for trial-specific information.

When a discrepancy exists between this Medicare Advantage medical policy and Medicare source materials (statutes, regulations, NCDs, LCDs, manuals), Medicare source materials take precedence. This policy is intended to support UnitedHealthcare coverage decision making but does not replace Medicare source documents.

Listing of a procedure or diagnosis code in this policy is for reference only. Inclusion of a code does not imply the service is covered or non‑covered and does not guarantee reimbursement or payment. Benefit coverage is determined by the member’s specific benefit plan and applicable laws; additional policies or guidelines may apply.

Some clinical coverage criteria for items or services have not been fully established in Medicare guidance. In situations where applicable Medicare statutes, regulations, NCDs, or LCDs are absent or allow for flexibility, UnitedHealthcare applies internal coverage criteria developed from review of clinical evidence and guidelines; these internal criteria are used to determine whether a service may be reasonable and necessary under certain circumstances.

Applicable Procedure and Device Codes

Applicable CPT Codes (selected excerpt)CPT

93050	Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive
93653	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3- dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re- entry.
93656	Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed.
37230	Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (Deleted 12/31/2025- see 37284, 37286, 37292, 37294)

Lower Extremity Endovascular Revascularization CPT CodesCPT

37231	Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (Deleted 12/31/2025- see 37284, 37286, 37292, 37294).
37254	Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel.
37256	Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel.
37258	Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel.
37260	Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel.
37263	Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel.
37265	Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel.
37267	Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel.
37269	Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel.
37271	Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel.

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IPAPS and Transcatheter Pulmonary Valve CPT CodesCPT

33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional
33477	Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

HCPCS Device CodesHCPCS

C2624

Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components

Covered CPT CodesCPTCovered

33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional
33477	Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

HCPCSHCPCSCovered

C2624

Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components

Remote monitoring interval — 93264 (brief) - inv-15

Interval for remote monitoring (93264)Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, with at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s)

Maximum monitoring windowUp to 30 days per monitoring episode as specified in code descriptor 93264

Download frequency requirementAt least weekly downloads of pulmonary artery pressure recordings are required during the monitoring period

Provider deliverableInterpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional are included in the monitoring service

Provider Responsibilities, Prior Authorization, and Claims

Prior Authorization

Prior Authorization for Cardiology Imaging

Some cardiology imaging services require plan-specific prior authorization. Refer to the Cardiology Prior Authorization and Notification resources at UHCprovider.com for program details and submission instructions.

See UHCprovider.com > Cardiology Prior Authorization and Notification

Prior Authorization

Follow Delegate Prior Authorization

Where a delegate (third‑party administrator) manages utilization management and prior authorization for a member, providers must follow the delegate’s prior authorization requirements and submission processes to avoid denials or delays.

Follow delegate requirements when applicable

Background and Policy Scope

This Medicare Advantage medical policy provides an overview of coverage references for multiple cardiovascular diagnostic and therapeutic procedures and directs readers to specific UnitedHealthcare policies and CMS materials for detailed medical necessity rules. Where a CMS National Coverage Determination (NCD) or Local Coverage Determination (LCD)/Local Coverage Article (LCA) exists, that CMS guidance is followed; where no CMS decision exists, the policy points readers to UnitedHealthcare commercial or Medicare Advantage policies (for example: Radiologic Diagnostic Procedures; Catheter Ablation for Atrial Fibrillation; Lower Extremity Endovascular Procedures; Transcatheter Procedures for Heart Valve Conditions) and to InterQual criteria as applicable.

The policy highlights specific Medicare positions for select procedures (for example, a Medicare NCD exists for lower extremity percutaneous transluminal angioplasty without stenting/atherectomy and CMS NCD 20.36 governs implantable pulmonary artery pressure sensors). It also directs providers to consult the CMS Coverage with Evidence Development (CED) trial list and related Medicare documents when trial‑based coverage or investigational device exemptions may apply.

For operational use, providers and utilization reviewers should use CMS tables and the Medicare Coverage Database first; if no applicable NCD/LCD/LCA is identified, follow the coverage criteria set forth in the Coverage Rationale and related UnitedHealthcare policy sections referenced in this document.

Key Definitions

Percutaneous Transluminal Angioplasty (PTA) — NCD and scope - inv-25

Medicare NCD for PTA without stenting/atherectomyMedicare has an NCD for lower extremity (iliac, femoral, and popliteal arteries) percutaneous transluminal angioplasty (PTA) without stenting and/or atherectomy (NCD 20.7)

PTA with stenting/atherectomy statusMedicare does not have an NCD for lower extremity PTA with stenting and/or atherectomy; where LCDs/LCAs exist, compliance with those policies is required

Guidance when no LCD/LCA existsFor states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Lower Extremity Endovascular Procedures

Scope noteThe NCD covers PTA without stenting/atherectomy in the iliac, femoral, and popliteal arteries; other lower extremity open endovascular procedures lack an NCD

Implantable Pulmonary Artery Pressure Sensor (IPAPS) — definition & CMS NCD - inv-26

OpenPayer

Cardiovascular Diagnostic and Therapeutic Procedures

Coverage Criteria and Application

Applicable Procedure and Device Codes

Provider Responsibilities, Prior Authorization, and Claims

Background and Policy Scope

Key Definitions