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    OpenPayerPolicy UpdatesVascular/Cardiothoracic SurgeryPriority Health Medicare VAD Coverage | OpenPayer
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    CurrentPriority Health MedicarePolicy 91509

    Ventricular Assist Devices & Artificial Hearts

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    Coverage criteria and medical necessity requirements for ventricular assist devices, percutaneous right ventricular assist devices, total artificial hearts, and related remote vital-sign monitoring.

    Policy Summary
    PayerPriority Health Medicare
    PolicyVentricular Assist Devices & Artificial Hearts
    Policy CodePolicy N/A
    Change TypeCoding-only revision
    Effective Date09/01/2026
    Next Review DateN/A
    Key ActionSubmit an advance care planning assessment completed by a qualified provider with every VAD or artificial-heart request.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    Removed the prior authorization note for HCPCS code Q0508 when charges exceeded specified dollar thresholds.

    0Changes to medical necessity criteria
    14 daysMaximum qualifying percutaneous RVAD duration
    ≥1.5 m²Percutaneous RVAD body-surface-area threshold
    NYHA IVBridge-to-transplant severity requirement
    10Minimum durable LVAD implants by a qualified surgeon
    Q0508Implanted VAD miscellaneous supplies requiring prior authorization

    Medical Necessity and Coverage Criteria

    Advance care planning

    Members receiving a VAD or artificial heart must have the following completed:

    Advance care planning assessment

    • An advance care planning assessment must be completed by a qualified provider.

      The assessment should accompany the request and applies to members receiving a VAD or artificial heart before or after surgery.

    Extracorporeal and intracorporeal LVADs

    Covered when the applicable InterQual criteria are met.

    Extracorporeal LVAD

    • Insertion of an extracorporeal left ventricular assist device is medically necessary when the applicable InterQual criteria are met.Applicable InterQual criteria

      InterQual CP:Procedures, Subset: Left Ventricular Assist Device (LVAD) Insertion.

    Intracorporeal LVAD

    • Insertion of an intracorporeal left ventricular assist device is medically necessary when the applicable InterQual criteria are met.Applicable InterQual criteria

    Percutaneous LVAD

    Covered for FDA-approved indications; otherwise considered experimental and investigational.

    • Insertion of a percutaneous left ventricular assist device, such as the TandemHeart or Impella, is medically necessary for an FDA-approved indication.FDA-approved indication

    Percutaneous right ventricular assist devices

    All of the following conditions must be met:

    Percutaneous RVAD eligibility

    • The device is an Impella RP System or Impella 5.5 with SmartAssist.
    • The patient is a child or adult with a body surface area of at least 1.5 m².BSA ≥ 1.5 m²
    • The device is used for treatment of acute right heart failure or decompensation.
    • The requested duration does not exceed 14 days.Up to 14 days

    • Qualifying precipitating event

    Artificial heart bridge to transplant

    Covered when all applicable bridge-to-transplant criteria are met:

    Bridge-to-transplant total artificial heart

    • The device is an FDA-approved total artificial heart, such as the CardioWest Total Artificial Heart.
    • The member is eligible for heart transplantation.
    • The member is awaiting heart transplantation.
    • The member is at imminent risk of death due to biventricular failure.NYHA Class IV

    Artificial heart destination therapy

    May be medically necessary in selected cases:

    Destination therapy total artificial heart

    • Use of a total artificial heart as permanent treatment, as an alternative to heart transplantation, may be considered medically necessary.

    Remote vital-sign monitoring enhancements

    Not medically necessary:

    Enhanced remote vital-sign monitoring

    • Real-time at-home or remote monitoring of vital signs through Bluetooth or similarly enabled or enhanced meters, blood-pressure cuffs, scales, thermometers, pulse oximeters, or similar devices is not medically necessary because the enhancements are for convenience.

    Investigational treatment exception

    Individual case review may allow coverage for care or treatment that is investigational yet promising for the conditions described.

    Qualifying serious illness

    • The condition is a terminal illness.
    • The condition is chronic, life-threatening, severely disabling, and causing serious clinical deterioration.

    Exception review for experimental, investigational, or unproven treatment

    Coverage exclusion for experimental, investigational, or unproven treatment may be reviewed for an exception when the applicable serious disease conditions are present.

    Qualifying serious illness

    • Terminal illness

      • The condition is a terminal illness.

    • Severe chronic illness

      • The condition is chronic, life-threatening, severely disabling, and causing serious clinical deterioration.

    Percutaneous left ventricular assist devices (LVADs) are medically necessary only for FDA-approved indications. Use for any other indication is considered experimental and investigational because of insufficient evidence in the peer-reviewed literature.

    Additional costs for Bluetooth or similarly enabled remote vital-monitoring enhancements—including enhanced meters, cuffs, scales, thermometers, pulse oximeters, or similar devices—over conventional instruments are excluded from reimbursement.

    Experimental, investigational, or unproven treatment is excluded from coverage unless an exception is reviewed. An exception may be considered when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

    The exclusion for experimental, investigational, or unproven treatment may be reviewed through the plan’s individual-case process when an applicable exception is present. Requests require prior plan approval, and coverage is not automatic; determinations are made by a Priority Health medical director or clinical pharmacist.

    Real-time at-home or remote monitoring of vital signs through Bluetooth or similarly enabled or enhanced devices is not medically necessary because these enhancements are considered a convenience. This includes monitoring of measures such as INR, blood pressure, weight, temperature, and oxygen saturation.

    Diagnosis, Procedure, Product, and Supply Codes

    ICD-10 Codes that may support medical necessityICD-10
    I11.0-I11.9Hypertensive heart disease
    ICD-10 Codes that may support medical necessityICD-10
    I13.0-I13.2Hypertensive heart and chronic kidney disease
    I21.01-I21.A9Acute myocardial infarction
    I22.0-I22.9Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
    I23.0-I23.8Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, including complications within the 28-day period
    ICD-10 Codes that may support medical necessityICD-10
    I42.0-I42.9Cardiomyopathy
    Percutaneous LVADs for non-FDA-approved indicationsmixedExperimental
    No codes listed
    FDA product codesmixed
    DSQVentricular (Assist) Bypass
    LOZArtificial Heart
    OZDTemporary non-roller type left heart support blood pump
    QNRBlood Pump For Ecmo, Long-Term (> 6 Hours) Use
    ICD-10 diagnosis codesICD-10
    I22.0-I22.9Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
    I23.0-I23.8Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period)
    I42.0-I42.9Cardiomyopathy
    I43Cardiomyopathy in diseases classified elsewhere
    I50.1-I50.9Heart failure
    I51.5Myocardial degeneration
    I51.7Cardiomegaly
    Myocardial infarction diagnosis codesICD-10
    I23.0-I23.8Code range referenced in the myocardial infarction coding context, including non-ST elevation myocardial infarction within the 28 day period
    Cardiomyopathy, heart failure, myocardial degeneration, and cardiomegaly diagnosis codesICD-10
    I42.0-I42.9Cardiomyopathy
    I43Cardiomyopathy in diseases classified elsewhere
    I50.1-I50.9Heart failure
    I51.5Myocardial degeneration
    I51.7Cardiomegaly
    ICD-10 Diagnosis CodesICD-10
    I42.0-I42.9Cardiomyopathy
    I43Cardiomyopathy in diseases classified elsewhere
    I50.1-I50.9Heart failure
    I51.5Myocardial degeneration
    I51.7Cardiomegaly
    I51.9Heart disease, unspecified
    R57.0Cardiogenic shock
    T82.221A-T82.228SMechanical complication of biological heart valve graft
    T82.512A-T82.512SBreakdown (mechanical) of artificial heart
    T82.518A-T82.518SBreakdown (mechanical) of other cardiac and vascular devices and implants
    1–10 of 25
    1/3
    CPT CodesCPTCovered
    33927Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy
    33928Removal and replacement of total replacement heart system (artificial heart)
    33929Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure)
    33975Insertion of ventricular assist device; extracorporeal, single ventricle
    33976Insertion of ventricular assist device; extracorporeal, biventricular
    33977Removal of ventricular assist device; extracorporeal, single ventricle
    33978Removal of ventricular assist device; extracorporeal, biventricular
    33979Insertion of ventricular assist device, implantable intracorporeal, single ventricle
    33980Removal of ventricular assist device, implantable intracorporeal, single ventricle
    33981Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump
    1–10 of 19
    1/2
    HCPCS CodesHCPCSCovered
    L8698Miscellaneous component, supply or accessory for use with total artificial heart system
    Q0477Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only
    Q0478Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type
    Q0479Power module for use with electric or electric/pneumatic ventricular assist device, replacement only
    Q0480Driver for use with pneumatic ventricular assist device, replacement only
    Q0481Microprocessor control unit for use with electric ventricular assist device, replacement only
    Q0482Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only
    Q0483Monitor/display module for use with electric ventricular assist device, replacement only
    Q0484Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
    Q0485Monitor control cable for use with electric ventricular assist device, replacement only
    1–10 of 33
    1/4
    Related proceduresCPT
    33967Insertion of intra-aortic balloon assist device, percutaneous
    33968Removal of intra-aortic balloon assist device, percutaneous
    33970Insertion of intra-aortic balloon assist device through the femoral artery, open approach
    33971Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft
    33973Insertion of intra-aortic balloon assist device through the ascending aorta
    33974Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft
    92970Cardioassist-method of circulatory assist; internal
    92971Cardioassist-method of circulatory assist; external
    Related proceduresCPT
    33967*Insertion of intra-aortic balloon assist device, percutaneous.
    33968*Removal of intra-aortic balloon assist device, percutaneous.
    33970*Insertion of intra-aortic balloon assist device through the femoral artery, open approach.
    33971*Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft.
    33973*Insertion of intra-aortic balloon assist device through the ascending aorta.
    33974*Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft.
    92970*Cardioassist-method of circulatory assist; internal.
    92971*Cardioassist-method of circulatory assist; external.
    Percutaneous RVAD duration
    Coverage durationUp to 14 days
    Qualifying devicesImpella RP System or Impella 5.5 with SmartAssist
    Clinical useAcute right heart failure or decompensation following LVAD implantation, myocardial infarction, heart transplant, or open-heart surgery
    Percutaneous RVAD body surface area

    Authorization and Documentation Requirements

    Documentation Required

    Advance Care Planning Assessment Required

    Complete and submit an advance care planning assessment performed by a qualified provider with every VAD or artificial-heart request, whether preoperative or postoperative.

    • The assessment should accompany the request.
    Prior Authorization

    Artificial Heart Bridge-to-Transplant Authorization

    Submit artificial-heart bridge-to-transplant requests through the designated Solid Organ Transplant prior-authorization pathway.

    • Applies to an FDA-approved total artificial heart used as a bridge to transplant for an eligible member with imminent risk of death from NYHA Class IV biventricular failure while awaiting transplantation.
    • Use the Solid Organ Transplant prior authorization form.

    Clinical Background

    Ventricular assist devices (VADs) support the left ventricle, right ventricle, or both while the native heart remains in place. They function as auxiliary pumps using a pump, control system, and energy supply. VAD support may be used as a bridge to transplant, to facilitate recovery from reversible cardiac dysfunction, or as destination therapy for selected patients with end-stage heart failure who are not transplant candidates. A total artificial heart replaces both ventricles and may provide temporary support while awaiting transplantation or permanent destination therapy.

    Key Terms

    Ventricular assist device (VAD)
    DefinitionA device that assists the left ventricle, right ventricle, or both while the native heart remains in place
    FunctionWorks with the patient's own heart as an auxiliary or parallel pump to pump sufficient blood throughout the body
    ComponentsPump, control system, and energy supply
    Total artificial heart (TAH)
    DefinitionAn implantable, pneumatic, biventricular support device
    FunctionServes as a total replacement for both ventricles of the failing heart
    Support type
    Policy Summary
    PayerPriority Health Medicare
    PolicyVentricular Assist Devices & Artificial Hearts
    Policy CodePolicy N/A
    Change TypeCoding-only revision
    Effective Date09/01/2026
    Next Review DateN/A
    Key ActionSubmit an advance care planning assessment completed by a qualified provider with every VAD or artificial-heart request.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaDiagnosis, Procedure, Product, and Supply CodesAuthorization and Documentation RequirementsClinical BackgroundKey Terms
  1. Acute right heart failure or decompensation follows left ventricular assist device implantation.
  2. Acute right heart failure or decompensation follows myocardial infarction.
  3. Acute right heart failure or decompensation follows heart transplant.
  4. Acute right heart failure or decompensation follows open-heart surgery.
    5. Qualifying body surface areaBSA ≥ 1.5 m²
    Patient populationChild or adult
    Required conditionAcute right heart failure or decompensation
    Bridge-to-transplant heart-failure severity
    Required NYHA classificationNYHA Class IV
    Intended useBridge to transplant with an FDA-approved total artificial heart
    Clinical statusTransplant-eligible member at imminent risk of death due to biventricular failure while awaiting heart transplantation
    Durable intracorporeal LVAD surgeon experience
    Minimum implant volumeAt least 10 durable, intracorporeal left VADs
    Review periodPrevious 36 months
    Recent activityActivity in the last year
    Post-myocardial-infarction complication period
    Referenced code rangeI23.0-I23.8
    Coding subjectCertain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
    Referenced periodWithin the 28 day period
    Myocardial infarction coding period
    Referenced code rangeI22.0-I22.9 and I23.0-I23.8
    Diagnosis contextSubsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, including certain current complications
    Referenced periodWithin the 28 day period
    Documentation Required

    Device and Indication Details

    Document the device category and the clinical indication supporting the request.

    • Identify whether the request is for an extracorporeal, intracorporeal, or percutaneous LVAD; a percutaneous RVAD; or a total artificial heart.
    • For percutaneous LVADs, specify the FDA-approved indication because use for other indications is experimental and investigational.
    Documentation Required

    Percutaneous RVAD Eligibility

    For a percutaneous RVAD request, document all eligibility elements required by the policy.

    • Identify the Impella RP System or Impella 5.5 with SmartAssist.
    • Document that the member is a child or adult, has BSA ≥ 1.5 m², and requires treatment for acute right-heart failure or decompensation following LVAD implantation, myocardial infarction, heart transplant, or open-heart surgery.
    • Coverage is limited to up to 14 days.

    Unsupported block type: documentation

    Prior Authorization

    Medical-Necessity Prior Authorization

    Prior authorization may be required for certain devices, services, procedures, and drugs. When required, submit a request demonstrating medical necessity and supporting the requested service.

    • Follow the Priority Health Provider Manual and the applicable authorization pathway.
    • Include clinical documentation supporting the diagnosis, requested treatment, and medical-necessity criteria.
    Prior Authorization

    Individual Consideration Requires Prior Approval

    Requests for individual consideration of investigational yet promising treatment require prior plan approval.

    • Coverage determinations for experimental, investigational, or unproven treatment are made by a Priority Health medical director or clinical pharmacist.
    Denial Risk

    Experimental or Unproven Treatment Exclusion

    Treat experimental, investigational, or unproven treatment as excluded unless an exception is approved through review.

    • An exception review may be available when the condition is terminal or is a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.
    • Submit documentation supporting the applicable exception and the requested treatment.
    Prior Authorization

    Implanted VAD Miscellaneous Supply

    Obtain prior authorization for miscellaneous supplies or accessories for an implanted ventricular assist device when required by the applicable HCPCS code.

    • Q0508 identifies miscellaneous supplies or accessories for an implanted ventricular assist device as requiring prior authorization.
    • Verify the specific code and authorization requirement before submitting the claim.
    Denial Risk

    Enhanced Remote Vital Monitoring Not Medically Necessary

    Do not request enhanced remote vital-sign monitoring as medically necessary solely because it uses Bluetooth or similar connectivity.

    • Real-time at-home or remote monitoring enhancements for INR, blood pressure, weight, temperature, oxygen saturation, or similar measurements are considered not medically necessary.
    • Priority Health will not reimburse additional costs for enhanced equipment over conventional instruments.
    Note

    Controlling Benefit or Plan Document

    Coverage is subject to the member’s specific benefits and controlling plan documents.

    • A group-specific policy, individual policy, self-funded plan document, or other applicable benefit document may supersede or alter this policy.
    • If a policy conflicts with the applicable plan document, the plan document governs; for Medicare members, CMS coverage determinations govern when applicable.
    May be used temporarily before heart transplantation or permanently as destination therapy
    Bridge to transplant
    DefinitionUse of mechanical circulatory support to sustain a patient while awaiting heart transplantation
    PurposeProvides temporary support before transplantation
    Applicable supportMay involve a ventricular assist device or total artificial heart
    Destination therapy
    DefinitionPermanent mechanical circulatory support used as an alternative to heart transplantation
    Clinical useMay be considered for patients with severe, irreversible biventricular heart failure who are not candidates for transplantation
    Treatment intentPermanent treatment rather than temporary support while awaiting a donor heart