Highmark Medical Policy Bulletin
Section: Surgery
Number: S-153
Topic: Biventricular Pacemakers for the Treatment of Congestive Heart Failure
Effective Date: August 26, 2002
Issued Date: August 28, 2006
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Insertion of the biventricular pacemaker may be considered medically necessary as a treatment of congestive heart failure in patients who meet all of the following criteria:

  • New York Heart Association Class III or IV
  • Left ventricular ejection fraction < 35%
  • QRS duration of ≥ 130 msec
  • Patients treated with a stable pharmacological medical regimen prior to implant, including an ACE inhibitor (or an angiotensin receptor blocker) and a beta blocker (or angiotensin receptor blocker), digoxin, and diuretics
If the insertion of a biventricular pacemaker for congestive heart failure is reported for any indication other than those listed, it should be denied as not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

For information on standard pacemakers, see Medical Policy Bulletin G-14.

Description

Individuals with congestive heart failure typically experience fatigue and shortness of breath during exertion and, therefore, have difficulty performing many of the routine tasks of daily living.

The biventricular pacemaker used for the treatment of congestive heart failure consists of a pulse generator that is implanted in the chest and connected to the heart by three wires (leads) that deliver electrical impulses. One wire is placed in the upper right heart chamber and the others are placed in each of the two lower chambers, where they simultaneously stimulate both the left and right ventricles. This device differs from a standard pacemaker in that it has three leads instead of one or two leads.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

93799     

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

MPRM 2.02.10

Effects of Multisite Biventricular Pacing in Patients with Heart Failure and Intraventricular Conduction Delay, The New England Journal of Medicine, Vol. 344, No. 12, 03/2001

Acute Effects of Cardiac Resynchronization Therapy on Left Ventricular Doppler Indices in Patients with Congestive Heart Failure, American Heart Journal, Vol. 143, No. 1, 01/2002

Efficacy of Biventricular Pacing on Myocardial Glucose Metabolism in Patients with Heart Failure Using 2-deoxy-2[18F] Fluoro-d-glucose Positron Emission Tomography: a case report, Journal of Cardiology, Vol. 39, No. 3, 03/2002

View Previous Versions

[Version 003 of S-153]
[Version 002 of S-153]
[Version 001 of S-153]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.