III.219 BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
III.219
III.219 BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
Policy
INTERQUAL CRITERIA
These criteria include the following procedure:
Cardiac Resynchronization Therapy (CRT)
Cardiac Resynchronization Therapy-Defibrillator (CRT-D) Insertion
Cardiac Resynchronization Therapy-Implantable Cardioverter Defibrillator (CRT-ICD) Insertion
Biventricular pacemaker with and without ICD
InterQual® Procedures criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, the Cochrane Library, Choosing Wisely, Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations, the National Institute of Health and Care Excellence (NICE), and the National Guideline Clearinghouse. Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been used.
Dates
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Original Effective
04-15-2015
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Last Review
05-07-2025
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Next Review
05-05-2026
Description
Biventricular pacemaker insertion involves the placement of electrodes into both the right atrium and right ventricle, as well as a third transvenous lead into the external wall of the left ventricle. It is technically more demanding than the insertion of a conventional pacemaker and may require echocardiography or coronary venogram to determine proper placement of the electrodes. Meta-analysis of multiple trials has shown implant success rates of 93% with procedure complication and mortality rates of 4.3% and 0.3%, respectively (1) Cardiac resynchronization therapy, in addition to optimal medical treatment or defibrillator insertion, significantly reduces mortality rates for patients with heart failure. (2)
Cardiac resynchronization therapy (CRT) with a biventricular pacemaker aims to improve the pumping efficiency of the heart by enabling synchronous ventricular contraction after the device senses atrial systole. Several trials have demonstrated the efficacy of CRT in improving functional status and quality of life, improving ejection fraction, and reducing overall mortality and hospitalizations for heart failure in patients with Class II, Class III, and Class IV New York Heart Association heart failure. (3, 4, 5, 6)
These criteria do not cover biventricular pacing or cardiac resynchronization therapy (CRT) in patients with asymptomatic or New York Heart Association (NYHA) Class I heart failure (HF). The Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) failed to show a significant reduction in the primary end-points of death or HF events with combined CRT and implantable cardioverter defibrillator (ICD) therapy over ICD therapy alone in patients with NYHA Class I HF. (7) There was also a trend towards less clinical efficacy by CRT in NYHA Class I patients compared to NYHA Class II patients in the REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) trial. (8)
The number of NYHA Class I patients compared to NYHA Class II patients enrolled in CRT trials is significantly smaller and current guidelines do not recommend CRT for patients with NYHA Class I HF. A systematic review demonstrated a significant reduction in HF events and hospitalizations with the use of CRT in asymptomatic patients with NYHA Class I HF; however, the risks and benefits of device implantation in an asymptomatic patient need careful consideration. (3, 4, 5, 6, 9)
Quick Code Search
Procedure
Diagnosis
Codes
Insertion of Pacemaker Lead into Coronary Vein, Open Approach
Insertion of Defibrillator Lead into Coronary Vein, Open Approach
Insertion of Cardiac Lead into Coronary Vein, Open Approach
Insertion of Defibrillator Lead into Coronary Vein, Percutaneous Approach
Insertion of Cardiac Lead into Coronary Vein, Percutaneous Approach
Insertion of Pacemaker Lead into Coronary Vein, Percutaneous Endoscopic Approach
Insertion of Defibrillator Lead into Coronary Vein, Percutaneous Endoscopic Approach
Insertion of Cardiac Lead into Coronary Vein, Percutaneous Endoscopic Approach
Insertion of Pacemaker Lead into Right Atrium, Open Approach
Insertion of Defibrillator Lead into Right Atrium, Open Approach
Insertion of Cardiac Lead into Right Atrium, Open Approach
Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach
Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach
Insertion of Cardiac Lead into Right Atrium, Percutaneous Approach
Insertion of Pacemaker Lead into Right Atrium, Percutaneous Endoscopic Approach
Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach
Insertion of Cardiac Lead into Right Atrium, Percutaneous Endoscopic Approach
Insertion of Pacemaker Lead into Left Atrium, Open Approach
Insertion of Defibrillator Lead into Left Atrium, Open Approach
Insertion of Cardiac Lead into Left Atrium, Open Approach
Insertion of Pacemaker Lead into Left Atrium, Percutaneous Approach
Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach
Insertion of Cardiac Lead into Left Atrium, Percutaneous Approach
Insertion of Pacemaker Lead into Left Atrium, Percutaneous Endoscopic Approach
Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach
Insertion of Cardiac Lead into Left Atrium, Percutaneous Endoscopic Approach
Insertion of Pacemaker Lead into Right Ventricle, Open Approach
Insertion of Defibrillator Lead into Right Ventricle, Open Approach
Insertion of Cardiac Lead into Right Ventricle, Open Approach
Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approach
Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach
Insertion of Cardiac Lead into Right Ventricle, Percutaneous Approach
Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Endoscopic Approach
Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach
Insertion of Cardiac Lead into Right Ventricle, Percutaneous Endoscopic Approach
Insertion of Pacemaker Lead into Left Ventricle, Open Approach
Insertion of Defibrillator Lead into Left Ventricle, Open Approach
Insertion of Cardiac Lead into Left Ventricle, Open Approach
Insertion of Pacemaker Lead into Left Ventricle, Percutaneous Approach
Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach
Insertion of Cardiac Lead into Left Ventricle, Percutaneous Approach
Insertion of Pacemaker Lead into Left Ventricle, Percutaneous Endoscopic Approach
Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach
Insertion of Cardiac Lead into Left Ventricle, Percutaneous Endoscopic Approach
Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Cardiac Rhythm Related Device into Chest Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Rhythm Related Device into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Cardiac Rhythm Related Device into Abdomen Subcutaneous Tissue and Fascia, Open Approach
Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of Cardiac Rhythm Related Device into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)
Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)
Insertion of implantable defibrillator pulse generator only; with existing single lead
Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber
References
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2007
McAlister et al. Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review. JAMA 2007. 297(22):2502-2514. |
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2011
Wells et al. Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials. CMAJ 2011. 183(4):421-9. |
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2016
Ponikowski P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016. |
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2015
Priori et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015. 36(41):2793-867. |
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2013
Brignole et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013. 34(29):2281-329. |
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2012
Epstein et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2013. 127(3):e283-352. |
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2009
Moss et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med 2009. 361(14):1329-1338. |
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2009
Daubert et al. Prevention of disease progression by cardiac resynchronization therapy in patients with asymptomatic or mildly symptomatic left ventricular dysfunction: insights from the European cohort of the REVERSE (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction) trial. J Am Coll Cardiol 2009. 54(20):1837-1846. |
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2011
Adabag et al. Cardiac resynchronization therapy in patients with minimal heart failure: a systematic review and meta-analysis. J Am Coll Cardiol 2011. 58(9):935-41. |
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2013
Yancy et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013 |
Revisions
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05-02-2024
Policy reviewed at Medical Policy Committee meeting on 05/01/2024 – no changes to policy. |
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08-26-2019
Removing 33208 33211 33213 as these are not appropriate for this policy |
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08-21-2019
Adding missing code 33208 to this policy. |
