CurrentUnitedHealthcarePolicy MMP240.15

Percutaneous Ventricular Assist Device

UnitedHealthcare Medicare Advantage medical policy governing when percutaneous insertion of an endovascular cardiac assist device (pVAD) is considered reasonable and necessary, associated applicable procedure/diagnosis codes, references to CMS LCDs/LCAs, clinical evidence, and FDA/ guideline context. Applies where no conflicting LCD/NCD exists; compliance with LCDs/LCAs required when present.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Ventricular Assist Device

Policy CodePolicy MMP240.15

Change TypeRevised (template update); administrative and code cleanup

Effective DateAug 1, 2024

Next Review Date

Key ActionProvider must document the patient has one of the three listed life-threatening situations and that IABP is not expected to be sufficient.

POLICY UPDATE CHANGES

Policy reformatted and reorganized to a new template; changed classification from 'Policy Guideline' to 'Medical Policy' and added Clinical Evidence, FDA, and References sections.

Updated CMS-related documents list and MAC/state jurisdictions; added Virginia jurisdiction notation.

Removed CPT codes 33992, 33993, and 33997 and ICD procedure code 5A02216 from Applicable Codes.

Replaced 'covered' wording with 'considered reasonable and necessary' in coverage rationale language.

Added reference link to the Medicare Advantage Medical Policy titled Cardiovascular Diagnostic and Therapeutic Procedures and removed reference link to an older Coverage Summary.

3Permitted life-threatening indications

3Referenced CPT/ICD code groups

Coverage Summary

Scope: UnitedHealthcare Medicare Advantage medical policy governing when percutaneous insertion of an endovascular cardiac assist device (pVAD) is considered reasonable and necessary, associated applicable procedure and diagnosis codes, references to CMS LCDs/LCAs, clinical evidence, and FDA/guideline context.

Coverage stance: Covered with criteria — percutaneous insertion of an endovascular cardiac assist device is considered reasonable and necessary only under specified conditions.

Subject: Percutaneous Ventricular Assist Device (pVAD) insertion.

Effective date: August 1, 2024; Status: CURRENT (Last committee approval: July 10, 2024).

Summary: UnitedHealthcare follows Medicare guidance (NCDs, LCDs/LCAs) where present; absent a Medicare NCD for pVAD, internal criteria apply and the policy summarizes limited situations where pVAD may be reasonable and necessary, relying on Medicare guidance when available.

Key Values

Permitted life-threatening indications3

Referenced code group count3

Last committee approval year2024

Policy numberMMP240.15

Effective date2024-08-01

Last review2024-07-10

Medically Necessary / Reasonable and Necessary Indications

Percutaneous insertion of an endovascular cardiac assist device is considered reasonable and necessary only when ALL of the following conditions are met:

ALL of the following

The patient has one of the following life-threatening situations:
- Cardiogenic shock
- Severe decompensated heart failure with threatening multi-organ failure
- Complications/disturbances of the circulatory system intra-operatively or postoperatively
External counterpulsation (intra-aortic balloon pump, IABP) is not expected to be sufficient

Applicable Codes

Referenced CPT procedure codes (insertion of ventricular assist device, percutaneous)CPTCovered

33990	Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; left heart arterial access only.
33991	Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture.
33995	Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only

Referenced ICD-10-CM diagnoses (conditions associated with potential coverage)ICD-10Covered

I5A	Non-ischemic myocardial injury (non-traumatic).
I50.1	Left ventricular failure, unspecified.
I50.20	Unspecified systolic (congestive) heart failure.
I50.21	Acute systolic (congestive) heart failure.
I50.22	Chronic systolic (congestive) heart failure.
I50.23	Acute on chronic systolic (congestive) heart failure.
I50.30	Unspecified diastolic (congestive) heart failure.
I50.31	Acute diastolic (congestive) heart failure.
I50.32	Chronic diastolic (congestive) heart failure.
I50.33	Acute on chronic diastolic (congestive) heart failure.

1–10 of 30

1/3

ICD-10-PCS procedure code (assistance with cardiac output using impeller pump)ICD-10Covered

5A0221D

Assistance with Cardiac Output using Impeller pump, Continuous

Note: The policy underwent a template update and content transfer on 08/01/2024, including a code list cleanup that removed CPT codes 33992, 33993, and 33997 and ICD procedure code 5A02216 from Applicable Codes.

Where applicable, providers should follow jurisdictional LCD/LCA coding and billing guidance (see CMS Local Coverage Determinations / Local Coverage Articles) and adhere to any Medicare Administrative Contractor (MAC) requirements, as UnitedHealthcare requires compliance with LCDs/LCAs when present.

Provider Actions & Requirements

Documentation Required

Document life-threatening indication and IABP insufficiency

Document that the patient meets one of the three life‑threatening indications (cardiogenic shock; severe decompensated heart failure with threatening multi‑organ failure; or intra‑operative or post‑operative complications/disturbances of the circulatory system) and that intra‑aortic balloon pump (IABP) counterpulsation is not expected to be sufficient.

Cardiogenic shock
Severe decompensated heart failure with threatening multi‑organ failure
Complications/disturbances of the circulatory system intra‑operatively or postoperatively

Documentation Required

Adhere to FDA approval guidelines

Coverage is considered only when the FDA approval guidelines for the specific device are adhered to strictly; providers must follow device FDA labeling/approval when seeking reasonable and necessary determination for pVAD use.

Background & Evidence

Background: UnitedHealthcare follows Medicare guidance (NCDs, LCDs/LCAs) where present; when Medicare does not have an NCD for a service, internal UnitedHealthcare criteria apply.

This policy references limited, specific situations in which percutaneous insertion of an endovascular cardiac assist device (pVAD) is considered reasonable and necessary and is based on an evaluation of clinical evidence and guideline recommendations.

Clinical evidence and guideline sources cited include Hayes assessments and randomized trials/meta-analyses showing improved hemodynamics but no consistent mortality benefit and increased adverse events, and professional society guidelines (ACC/AHA/SCAI, AHA/ACC/HFSA, ISHLT/HFSA) supporting selective use of temporary mechanical circulatory support in high-risk patients or cardiogenic shock.

Evidence Source	Summary
Hayes assessment (2022, updated 2024)	Low-quality evidence suggesting potential benefit of Impella in HRPCI; 2024 update: no change in rating
Randomized trials/meta-analyses	RCTs and meta-analyses: improved hemodynamics but no consistent mortality benefit; increased adverse events (bleeding, vascular complications)
Guideline recommendations	ACC/AHA/SCAI and AHA/ACC/HFSA support selective/temporary MCS in high‑risk patients or cardiogenic shock (strengths vary: e.g., 2A–2B/I–II)

Definitions

IABPIntra-aortic balloon pump (external counterpulsation) used as alternative mechanical circulatory support.

pVAD or pMCSPercutaneous ventricular assist device or percutaneous mechanical circulatory support (e.g., Impella, TandemHeart).

Medicare Determinations & Local Coverage

Medicare determinations: Medicare does not have a National Coverage Determination (NCD) for Percutaneous Ventricular Assist Device.

Local Coverage Determinations / Local Coverage Articles referenced in this policy include billing and coding articles A53986; A53988; A59657; A59658; A96526; and A52967 (various billing/coding LCAs and MAC-specific articles).

When an LCD/LCA exists for a state/territory or MAC jurisdiction, providers must follow that LCD/LCA; if no LCD/LCA exists for the jurisdiction, UnitedHealthcare’s internal criteria (as described in the Coverage Rationale) apply.

NCD presence	LCD/LCA articles
None	A53986; A53988; A59657; A59658; A96526; A52967

Revision History

08/01/2024template_update_content_transferLatest

Template update and content transfer: policy reformatted and reorganized into a new template; classification changed from 'Policy Guideline' to 'Medical Policy'; Clinical Evidence, FDA, and References sections added; coverage language updated to state 'reasonable and necessary' rather than 'covered'.

08/01/2024code_list_cleanup

Applicable codes cleaned up: CPT codes 33992, 33993, and 33997 and ICD procedure code 5A02216 were removed from the Applicable Codes list.

08/01/2024wording_clarification