Modifiedpriority healthPolicy N/A

Cardiology: Coverage Criteria for Cardiac Devices and Revascularization

Governs coverage, place-of-service, documentation, billing modifiers, and Medicare-specific requirements for cardiac devices (pacemakers, leadless pacemakers, ICDs, AEDs/vests) and peripheral arterial revascularization procedures for Priority Health members and applicable providers.

Policy Summary

Payerpriority health

PolicyCardiology: Coverage Criteria for Cardiac Devices and Revascularization

Policy CodePolicy N/A

Change TypeContent additions and TurningPoint management (material changes)

Effective DateJul 1, 2024

Next Review Date

Key ActionComplete a Pre‑Service Organization Determination (PSOD) for Medicare indications that do not meet NCD/LCD or specific policy guidance.

SourceLink

POLICY UPDATE CHANGES

Added 'Valve replacement' section.

Added 'Place of service' section specifying POS 21 for TAVR and mitral TEER; other POS codes will be denied.

Added 'Documentation requirements' and 'Disclaimer' sections.

Added sections for peripheral arterial revascularization, angioplasty/stenting, CABG, and implantable cardiac monitoring.

Priority Health contracted TurningPoint to manage some cardiac services; medical necessity governed by TurningPoint guidelines.

7device/procedure categories listed

TurningPointTurningPoint-managed services

Listrequired documentation elements

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.

MultipleCMS/Medicare references

Coverage Criteria

General coverage principles for revascularization

Covered when performed in accordance with CMS guidance, CPT coding instructions, and documentation that supports medical necessity. Priority Health follows CMS coverage and billing requirements; review applicable NCDs, LCDs and LCAs and consult CPT coding guidelines before assigning codes.

ALL of the following

The most comprehensive code describing the services performed at the given anatomic site/vessel is reported; when multiple codes describe services at the same site, report only the most comprehensive code.
When one lesion extends from one target vessel into another but can be revascularized with a single intervention treating both, report a single code rather than multiple codes for the vessels.
PCI procedure codes are hierarchical; more intensive services are inclusive of less intensive services. Less intensive services included in a higher-level code should not be reported separately (e.g., access/catheterization, lesion traversal, radiological supervision/interpretation).
Angiography performed during the procedure to monitor the intervention and deployment of embolic protection devices are considered inclusive and are not separately billable.
Devices must be FDA approved to be considered for payment.
Only one type of bypass procedure may be performed at a site of obstruction; if a procedure is started with one material but completed with another, report only the code describing the completed procedure.
Bypass graft includes blood vessel repair; CPT 35201-35286 should not be reported with a bypass graft code for the same anatomic site.
Postoperative hemorrhage CPT 35800-35860 may only be reported when the patient requires return to the operating room for treatment; these codes should not be applied on the initial operative session for postoperative hemorrhage treatment and appropriate modifier use is required.

TurningPoint-managed cardiac services

Medical necessity and coverage determinations for certain cardiac services are managed by TurningPoint Healthcare Solutions LLC and are governed by TurningPoint clinical guidelines.

ALL of the following

Medical necessity for TurningPoint-managed cardiac procedures will be governed by the applicable TurningPoint clinical guidelines; providers must follow those guidelines for coverage determinations.
To access TurningPoint guidelines, log into your Prism account, go to the Authorizations menu, click Authorization Criteria Lookup, then the TurningPoint link.
TurningPoint-managed code lists include, but are not limited to: 91597 (Transcatheter Heart Valve Procedures), 91636 (Category III CPT Codes), 91606 (Clinical Trials), 91495 (Carotid and Intracranial Artery Stenting).
Authorization and documentation requirements specified by TurningPoint must be met for payment; see TurningPoint criteria for procedure-specific clinical indications and exclusions.

CABG coding and reporting

CABG-specific coding and reporting rules — report only the most comprehensive code for the procedure and do not separately report items integral to the CABG.

ALL of the following

Only the most comprehensive code describing the CABG procedure should be reported for the operative session.
CABG procedures using venous grafts include procurement of the venous graft; ligation of the saphenous veins performed as part of graft procurement should not be reported separately.
Surgical removal of superficial or deep implants (e.g., sternal wires) performed on reoperation for CABG is considered integral to the procedure and is not separately reportable.
If a superficial or deep implant removal is performed as an integral part of another procedure, CPT 20670 and 20680 are considered inclusive and not separately reportable.

Confirm device status (FDA approval) and review CPT/HCPCS code descriptors and TurningPoint or CMS guidance to determine separate billability.

title

Device payment requirement

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Coding and Billing

Revenue codes and device coding referencesRevenue

0275	Revenue code referenced for implants

C-codes for devicesHCPCS

C Code

Specific implant device aligned with revenue code

HCPCS modifiers (DME/CMS guidance)Modifier

EY	No physician or other licensed health care provider order for this item or service
GA	Waiver of liability statement issued as required by payer policy, individual case
KF	Item designated by FDA as class III device
KX	Requirements specified in the medical policy have been met

General billing modifiers referencedModifier

KX	Requirements specified in the medical policy have been met
SC	Medically necessary service or supply
GA	Waiver of liability statement issued as required by payer policy
GZ	Item or service expected to be denied as not reasonable and necessary
Q0	Investigational clinical service provided in a clinical research study that is in an approved clinical research study

Non-coronary angioplasty related CPT (as cited)CPT

91636	Category III Current Procedural Terminology
91495	Carotid and Intracranial Artery Stenting

PCI vessel modifiersModifier

LD	Left anterior descending coronary artery modifier
LC	Left circumflex coronary artery modifier
RC	Right coronary artery modifier
LM	Left main artery modifier
RI	Rasmus intermedius artery modifier

General modifiersModifier

78	Unplanned Return to the Operating/Procedure Room
59	Distinct Procedural Service
XU	Unusual nonoverlapping service
XS	Separate structure

Referenced CPT/Categoriesmixed

91636	Category III Current Procedural Terminology
91495	Carotid and Intracranial Artery Stenting

Implantable Cardiac Monitor CPT/HCPCSCPT | HCPCSCovered

33285	Insertion, subcutaneous cardiac rhythm monitor, including programming
33286	Removal, subcutaneous cardiac rhythm monitor
93285	Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal programmed values with analysis, review and report by a physician or other qualified health care professional, subcutaneous cardiac rhythm monitor system
93291	Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter, subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis
93298	Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s), and report(s) by a physician or other qualified health care professional
0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professional
E0616	Implantable cardiac event recorder with memory, activator and programmer
C1764	Event recorder, cardiac (implantable) (facility only code)

Referenced Procedure/Policy Codesmixed

91597	Transcatheter Heart Valve Procedures
91636	Category III CPT Codes
91606	Clinical Trials

ModifiersModifier

26	Professional component modifier
TC	Technical component modifier
62	Two surgeons modifier
Q0	Investigational clinical service provided in a clinical research study

Remote interrogation frequency — 93298 limitation

Reporting frequencyCPT 93298 (remote interrogation of subcutaneous rhythm monitor) can be reported only once per 30 days.

Inclusion with E/MRemote monitoring episodes of less than 10 days are included in the work associated with the relevant E/M service code.

Related remote programming codeUse 0650T for remote programming device evaluation of subcutaneous cardiac rhythm monitor systems (see policy 91636).

Codes for device managementInterrogation and programming codes include 93285, 93291, 93298, and 0650T; review CPT descriptions for accurate assignment.

Provider Actions and Authorization Requirements

Prior Authorization

PSOD required for non‑covered Medicare indications

For Medicare indications that do not meet the criteria of an NCD, local LCD, or a specific medical policy, a Pre‑Service Organization Determination (PSOD) must be completed prior to service. Providers should consult the Provider Manual for PSOD process details. Applicable Medicare non‑coverage modifiers include GA (waiver of liability statement issued as required by payer policy) and GZ (item or service expected to be denied as not reasonable and necessary).

PSOD required prior to service for Medicare non‑covered indications
See Provider Manual for PSOD details
Applicable modifiers: GA, GZ

Denial Risk

Place‑of‑service denials

Claims billed with place‑of‑service (POS) codes outside of Priority Health's accepted POS list will be denied. Confirm the POS on the claim matches the setting in which the service was furnished.

Definitions

Permanent cardiac pacemaker — definition and key attributes

DefinitionPermanent cardiac pacemaker: a self-contained, battery-operated implanted device that sends electrical stimulation to the heart through one or more implanted leads.

Single vs dual chamberSingle chamber: lead placed in the atrium OR ventricle; Dual chamber: leads placed in both atrium AND ventricle.

Implant locationDevice is implanted subcutaneously with leads placed in the heart chambers to provide chronic pacing support.

Leadless pacemaker — definition

DefinitionLeadless pacemaker: a one-piece device implanted into a single heart chamber via a vein.

Single-chamber useDesigned to provide pacing to a single cardiac chamber without transvenous leads.

Background

Permanent cardiac pacemakers are self‑contained, battery‑operated implanted devices that deliver electrical stimulation to the heart via one or more implanted leads. A single‑chamber pacemaker uses a lead in either an atrium or a ventricle; a dual‑chamber pacemaker uses leads in both an atrium and a ventricle. These devices are used to treat bradyarrhythmias and related conduction disorders and must be documented appropriately for coverage and billing.

Policy Summary

Payerpriority health

PolicyCardiology: Coverage Criteria for Cardiac Devices and Revascularization

Policy CodePolicy N/A

Change TypeContent additions and TurningPoint management (material changes)

Effective DateJul 1, 2024

Next Review Date

Key ActionComplete a Pre‑Service Organization Determination (PSOD) for Medicare indications that do not meet NCD/LCD or specific policy guidance.

SourceLink

On This Page

Denied POS examples: POS 06 (Indian Health Service Provider Based Facility), POS 19 (Off Campus‑Outpatient Hospital), POS 22 (On Campus‑Outpatient Hospital), POS 26 (Military Treatment Facility)
Ensure POS accurately reflects where service was furnished

Billing Rule

Place of Service and billing compliance

Specific POS and billing rules apply to certain procedures (for example, TAVR and mitral TEER). Claims for TAVR and mitral TEER must be submitted with POS 21 (inpatient hospital); submissions with any other POS will be denied. Follow Priority Health billing and coding requirements; failure to follow billing, coding or documentation requirements may result in denial or recoupment.

TAVR and mitral TEER: POS 21 required; all other POS will be denied
Failure to follow billing/coding/documentation requirements may result in denial or recoupment

Documentation Required

Required documentation

Complete and thorough documentation per CMS standards is the responsibility of the provider and must substantiate the medical necessity and details of the procedure. Consult any applicable NCD, LCD or TurningPoint guideline for additional documentation requirements.

Documentation must support medical necessity and the performed procedure
Consult applicable NCD/LCD/TurningPoint guidelines for additional requirements

Documentation Required

Procedure documentation

Documentation should include relevant medical history, physical examination, results of pertinent diagnostic tests/procedures, a detailed description of the procedure performed (including devices/medications used), outcomes, complications or reasons the procedure was not completed, comparison with relevant studies, diagnosis/reason for the test, and justification for repeated services when applicable. For DME, include Standard Written Order (SWO) or Written Orders Prior to Delivery (WOPD) as applicable and item descriptions; when billing an unlisted HCPCS code, include item name, manufacturer, and rationale.

Relevant medical history and physical exam
Results of diagnostic tests/procedures
Detailed procedure description, devices/medications used, and outcomes
Documentation of complications or incomplete procedures
Comparison with prior studies and diagnosis or reason for test
DME: Standard Written Order (SWO) and WOPD if applicable
Unlisted HCPCS: include item name, manufacturer, and justification

Documentation Required

Modifier documentation

Modifiers must be applied in accordance with CMS, NCCI, and Priority Health guidance and only when supported by documentation. Incorrect application of modifiers will result in claim denials. See the Provider Manual and CMS NCCI guidance for proper use. Specific modifiers referenced in cardiac services include artery identifiers (LD, LC, RC, LM, RI) and others such as Modifier 62 (two surgeons) and Q0 (investigational clinical service in an approved study); ensure documentation supports their use.

Incorrect modifier application may result in denials
Specific artery modifiers: LD, LC, RC, LM, RI
Other referenced modifiers: 62 (two surgeons), Q0 (investigational clinical service)
Consult CMS NCCI and Provider Manual for detailed guidance

Prior Authorization

TurningPoint‑managed criteria

Priority Health has contracted with TurningPoint Healthcare Solutions LLC to manage certain cardiac services. Medical necessity for those procedures is governed by TurningPoint clinical guidelines, which may include stepwise or specific criteria. Providers must consult TurningPoint criteria via the Prism Authorization Criteria Lookup (TurningPoint link) when seeking authorization or preparing documentation.

TurningPoint governs medical necessity for specified cardiac procedures
Access TurningPoint guidelines via Prism: Authorizations → Authorization Criteria Lookup → TurningPoint
Follow TurningPoint stepwise criteria when applicable

Implant approachDelivered percutaneously through the venous system and affixed directly within the chamber.

Implantable cardioverter defibrillator (ICD) — definition

DefinitionImplantable cardioverter defibrillator (ICD): a surgically placed subcutaneous battery/pulse generator with leads positioned in heart chambers that can deliver electric shocks to correct life‑threatening arrhythmias and prevent sudden cardiac arrest.

ComponentsConsists of a pulse generator (battery) and transvenous leads/electrodes inserted into cardiac chambers.

Primary purposeDetect and terminate ventricular tachyarrhythmias via high-energy shock or anti-tachycardia pacing.

Automated External Defibrillator (AED) / Wearable vest — definition

AED definitionAutomated External Defibrillator (AED): a lightweight, battery-operated, portable device that checks heart rhythm and can deliver a shock to restore normal rhythm.

Wearable vestA vest worn under clothing with pads that monitor the heart and can deliver high-energy charges to treat dangerous arrhythmias or cardiac arrest.

Use caseIntended for emergency treatment of sudden cardiac arrest or continuous protection in high-risk patients (vest).

Peripheral revascularization — definition

DefinitionPeripheral revascularization: procedures to repair narrowing or blockages in leg (peripheral) arteries to restore blood flow.

Included methodsMay include angioplasty, stent placement, atherectomy, bypass, and endarterectomy.

Anatomic focusApplies to non-cardiac (peripheral) arterial circulation, typically lower extremity arteries.

Revascularization — definition

DefinitionRevascularization: repair of narrowing or blockages in arteries to allow blood flow using techniques such as angioplasty, stent, atherectomy, bypass, or endarterectomy.

ScopeTerm covers both peripheral and coronary procedures when used broadly to describe restoring blood flow.

GoalRestore and maintain adequate perfusion to the affected tissue or organ by removing or bypassing obstruction.

Percutaneous coronary intervention (PCI) — definition

DefinitionPercutaneous coronary intervention (PCI): non-surgical procedure to treat stenotic coronary arteries using a balloon or other catheter-delivered device; a stent may be placed and imaging may be used.

Access routesTypically performed via femoral (inguinal) or radial arterial access delivering devices to coronary blockage.

Procedural elementsBalloon inflation at the stenosis, optional stent placement, and intraprocedural imaging as indicated.

Non-coronary angioplasty / PTA — definition

DefinitionNon-coronary angioplasty / PTA: minimally invasive percutaneous transluminal angioplasty to treat narrow or blocked arteries outside the heart using a balloon catheter; a stent may be placed to keep the artery open.

Anatomic sitesApplies to peripheral vascular beds (e.g., lower extremity, carotid, renal arteries) rather than coronary arteries.

TechniqueCatheter-directed balloon dilation with optional stent deployment; may include adjunctive devices like atherectomy.

Coronary artery bypass grafting (CABG) — definition

DefinitionCoronary artery bypass grafting (CABG): surgical procedure to restore blood flow around a blocked heart artery by taking a healthy vessel from the chest or leg and connecting it below the blocked artery to improve myocardial blood flow.

Graft sourcesUses autologous vessels (e.g., saphenous vein) or arterial grafts harvested from chest/leg.

Coding noteOnly the most comprehensive code describing the procedure should be reported; venous graft procurement is included in CABG codes.

Implantable cardiac monitor (implantable loop recorder) — definition

DefinitionImplantable cardiac monitor (implantable loop recorder): a device placed just under the skin of the chest that records heartbeats continuously for up to three years.

Relevant CPT/HCPCSCodes include 33285 (insertion), 33286 (removal), 93285/93291 (in-person programming/interrogation), 93298 (remote interrogation), 0650T (remote programming), E0616 and C1764.

Service capture guidanceCarefully review CPT descriptions to select the correct code for insertion, interrogation, programming, or removal.

Valve replacement — definition

DefinitionValve replacement: surgical procedure to repair or replace a damaged heart valve (tricuspid, pulmonary, mitral, or aortic); the valve may be repaired with an annuloplasty ring or removed and replaced.

Prosthesis typesReplacement valves may be synthetic (mechanical) or tissue (bovine or porcine) grafts.

IndicationPerformed when a heart valve is diseased or damaged and does not function properly.