Draft Version
Effective as of April 01, 2026III.219 BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
III.219
Draft Version
Effective as of April 01, 2026III.219 BIVENTRICULAR PACEMAKER WITH AND WITHOUT ICD (PREAUTHORIZATION REQUIRED)
Policy
INTERQUAL CRITERIA
These criteria include the following procedure:
Pacemaker Insertion, Biventricular
Pacemaker Insertion, Biventricular + Implantable Cardioverter Defibrillator (ICD) Insertion
Implantable Cardioverter Defibrillator (ICD) Insertion
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.
SINGLE OR DUAL CHAMBER PERMANENT CARDIAC PACEMAKERS (NOT INCLUDING BIVENTRICULAR)
I. The Single Chamber and Dual Chamber Permanent Cardiac Pacemakers may be considered scientifically validated for either indication:
A. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, OR
B. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.
II. Services are investigational when the above criteria are not met.
III. The following indications are considered investigational for implanted permanent single chamber or dual chamber cardiac pacemakers:
- Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
- Asymptomatic first-degree atrioventricular block,
- Asymptomatic sinus bradycardia,
- Asymptomatic sino-atrial block or asymptomatic sinus arrest,
- Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
- Asymptomatic second-degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
- Syncope of undetermined cause,
- Bradycardia during sleep,
- Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
- Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
- Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
- A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.
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 epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach)
Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy)
Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial
Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING SINGLE LEAD
Insertion of pacemaker pulse generator only; with existing dual leads
Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode
Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator
Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator
REPAIR OF SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR
Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator
Insertion of pacemaker pulse generator only; with existing multiple leads
Relocation of skin pocket for implantable defibrillator
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)
Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system
Insertion of implantable defibrillator pulse generator only; with existing dual leads
Insertion of implantable defibrillator pulse generator only; with existing multiple leads
Insertion of implantable defibrillator pulse generator only; with existing single lead
Removal of implantable defibrillator pulse generator only
Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy
Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction
Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system
Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed
Insertion of subcutaneous implantable defibrillator electrode
Removal of subcutaneous implantable defibrillator electrode
Repositioning of previously implanted subcutaneous implantable defibrillator electrode
Cardioverter-defibrillator, single chamber (implantable)
Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing
References
|
2011
Wells et al. Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials. CMAJ 2011. 183(4):421-9. |
|
2007
McAlister et al. Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review. JAMA 2007. 297(22):2502-2514. |
|
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. |
|
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. |
|
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. |
|
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. |
|
2009
Moss et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med 2009. 361(14):1329-1338. |
|
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. |
|
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. |
|
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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04-01-2026
Effective 4/1/2026 codes updated: 33202, 33203, 33206, 33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33220, 33221, 33223, 33224, 33225, 33228, 33229, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, C1722, G0448 Added criteria for pacemakers & policy title was previously Biventricular pacemakers with and without ICD. New policy title: Pacemakers and Defibrillators. |
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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. |
