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    v1.0.28
    OpenPayerPolicy UpdatesCardiologyUnitedHealthcare Ventricular Assist Coverage | Ope…
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    CurrentUnitedHealthcarePolicy MMP240.18

    Percutaneous Ventricular Assist Device

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    This policy governs Medicare Advantage coverage of percutaneous insertion of an endovascular cardiac assist device. Coverage is limited to specified life-threatening cardiac conditions when an intra-aortic balloon pump is not expected to be sufficient and FDA approval requirements are strictly followed.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPercutaneous Ventricular Assist Device
    Policy CodePolicy MMP240.18
    Change TypeAdministrative and supporting-information updateno material clinical or coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionDocument the qualifying life-threatening condition, why an intra-aortic balloon pump is not expected to be sufficient, and adherence to FDA approval guidelines.
    SourceLink
    POLICY UPDATE CHANGES

    The CMS-related documents list and FDA section were updated, and prior policy version MMP240.17 was archived.

    3Specified life-threatening coverage situations
    47.8%30-day mortality in cited meta-analysis
    15.2%Major bleeding rate in cited meta-analysis
    Class 2A

    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.

    Advanced heart failure recommendation

    Percutaneous Ventricular Assist Device Coverage

    Percutaneous ventricular assist device coverage

    Covered as reasonable and necessary only when all of the following requirements are met.

    Limited coverage requirements

    • Qualifying life-threatening situation

      • Cardiogenic shock
      • Severe decompensated heart failure with threatening multi-organ failure
      • Intra-operative or postoperative circulatory complication: Complications or disturbances of the circulatory system intra-operatively or postoperatively
    • Alternative support insufficient: External counterpulsation, specifically an intra-aortic balloon pump, is not expected to be sufficient.
    • FDA compliance: The U.S. Food and Drug Administration approval guidelines are adhered to strictly.

    LCD or LCA compliance

    Where applicable, LCD and LCA requirements must also be met.

    Applicable Medicare coverage policies: For states or territories with applicable CMS Local Coverage Determinations or Local Coverage Articles, the provider must comply with those policies.

    If no applicable LCD or LCA is found, use the criteria in the Coverage Rationale.

    Procedure, Diagnosis, and Coverage Reference Codes

    Procedure CodesCPT
    33990Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only
    33991Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture
    33995Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
    Diagnosis CodesICD-10
    I5ANon-ischemic myocardial injury (non-traumatic)
    I50.1Left ventricular failure, unspecified
    I50.20Unspecified systolic (congestive) heart failure
    I50.21Acute systolic (congestive) heart failure
    I50.22Chronic systolic (congestive) heart failure
    I50.23Acute on chronic systolic (congestive) heart failure
    I50.30Unspecified diastolic (congestive) heart failure
    I50.31Acute diastolic (congestive) heart failure
    I50.32Chronic diastolic (congestive) heart failure
    I50.33Acute on chronic diastolic (congestive) heart failure
    1–10 of 29
    1/3
    CMS Related Local Coverage Articlesmixed
    A53986Billing and Coding: Percutaneous Ventricular Assist Device
    A53988Billing and Coding: Percutaneous Ventricular Assist Device
    A59657Billing and Coding: Artificial Hearts and Percutaneous Endovascular Cardiac Assist Procedures and Devices
    A59658Billing and Coding: Artificial Hearts and Percutaneous Endovascular Cardiac Assist Procedures and Devices; Retired 09/25/2025

    Authorization, Documentation, and Claim Responsibilities

    Prior Authorization

    Follow delegated prior-authorization requirements

    When a UnitedHealthcare Medicare Advantage plan uses a delegate to manage utilization management and prior authorization, follow the delegate’s requirements before requesting or providing the service.

    Documentation Required

    Document medical necessity and FDA compliance

    Document the qualifying life-threatening condition, why external counterpulsation with an intra-aortic balloon pump is not expected to be sufficient, and adherence to the device’s FDA approval guidelines.

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

    Percutaneous Ventricular Assist Devices

    Percutaneous ventricular assist devices are temporary mechanical circulatory support devices that provide hemodynamic assistance for selected critically ill patients with severe cardiac conditions. The policy describes their use in limited, life-threatening situations, including cardiogenic shock, severe decompensated heart failure with threatening multi-organ failure, and intra-operative or postoperative circulatory complications. Evidence remains limited, and clinical studies have generally not shown a consistent mortality advantage over intra-aortic balloon pump support while reporting risks such as bleeding, vascular injury, and limb ischemia.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPercutaneous Ventricular Assist Device
    Policy CodePolicy MMP240.18
    Change TypeAdministrative and supporting-information updateno material clinical or coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionDocument the qualifying life-threatening condition, why an intra-aortic balloon pump is not expected to be sufficient, and adherence to FDA approval guidelines.
    SourceLink
    On This Page
    Percutaneous Ventricular Assist Device CoverageProcedure, Diagnosis, and Coverage Reference CodesAuthorization, Documentation, and Claim ResponsibilitiesPercutaneous Ventricular Assist Devices
    Documentation Required

    Maintain supporting documentation

    Retain or have access to appropriate documentation when requested to support coverage decisions.

    Denial Risk

    Failure to meet limited coverage conditions

    The service may be denied when the indication is not one of the three specified life-threatening situations, when an intra-aortic balloon pump is expected to be sufficient, or when FDA approval guidelines are not strictly followed.

    Denial Risk

    Comply with applicable LCD or LCA

    For states or territories with applicable Local Coverage Determinations or Local Coverage Articles, comply with those policies. Failure to do so creates a denial risk.

    Denial Risk

    Verify the member-specific benefit plan

    Verify coverage against the member-specific benefit plan document and applicable laws before providing the service. Coverage may be limited or denied when the requested service conflicts with the plan document or applicable law; the member-specific plan document supersedes this policy in the event of a conflict.

    Prior Authorization

    Follow delegated utilization management

    For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management, follow the delegate’s utilization-management requirements. Failure to follow delegated requirements may jeopardize approval.

    Billing Rule

    Submit accurate claims

    Submit accurate claims using applicable CPT, CMS, and other coding guidelines. Inaccurate claims can result in payment or claim-processing problems, and following coding guidance does not guarantee claims payment.