Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Cardiac resynchronization therapy (CRT), which consists of synchronized pacing of the left and right ventricles, is intended to treat patients with heart failure and dyssynchronous ventricular contractions. Treatment involves placement of a device that paces both ventricles and which coordinates ventricular pacing to maximize cardiac pumping function and left ventricular ejection fraction (LVEF).
It is estimated that 20%-30% of patients with heart failure have intraventricular conduction disorders, resulting in a discoordinated contraction pattern and a wide QRS interval on the electrocardiogram. This abnormality appears to be associated with increased morbidity and mortality. Biventricular pacemakers using three leads (one in the right atrium and one in each ventricle) have been investigated as a technique to coordinate the contraction of the ventricles, thus improving the hemodynamic status of the patients. Two strategies are being explored: incorporating biventricular pacing into automatic implantable cardiac defibrillators (ICDs) and the development of stand-alone biventricular pacemakers.
There are numerous CRT devices, combined CRT-ICD devices (CRT-D), and combined CRT and fluid monitoring devices. Some of the devices are discussed here. A stand-alone biventricular pacemaker (InSync® Biventricular Pacing System, Medtronic) has received approval by the U.S. Food and Drug Administration (FDA) for the treatment of patients with New York Heart Association (NYHA) Class III or IV heart failure, on a stable pharmacologic regimen, who also have a QRS duration of >130 ms and a left ventricular ejection fraction of <35%. Biventricular pacemakers have also been combined with automatic implantable cardiacdefibrillators (AICDs).
Both Guidant (CONTAK CD ® CRT-D System) and Medtronic (InSync ®ICD Model 7272) have received FDA approval for combined cardiac resynchronization therapy defibrillators for patients at high risk of sudden cardiac death due to ventricular arrhythmias and who have NYHA Class III or IV heart failure with left ventricular ejection fraction of <35%, QRS duration >130ms (>120ms for the Guidant device) and remain symptomatic despite a stable, optimal heart failure drug therapy. See the Automatic Implantable Cardioverter Defibrillator (AICD) medical policy. In 2006, Biotronik Inc. received FDA approval for its combined ICD/CRT device with ventricular pacing leads (Tupos LV/ATx CRT-D/Kronos LV-T CRT-D systems); in 2013, the company received FDA approval for updated ICD/CRT devices (Ilesto/Iforia series).
In September 2010, the FDA expanded the indications for CRT to include patients with class I and II heart failure. In addition to NYHA class I/II heart failure, indications for CRT in mild heart failure include a left ventricular (LV) ejection fraction of less than 30% and a QRS duration of 130 ms or greater.
Multiple devices manufactured by Medtronic combine a CRT with the OpitVol™ monitoring system. For example, in 2005, the InSync Sentry system received FDA approval through the supplemental premarket approval (PMA) process. This combined biventricular pacemaker/AICD is additionally equipped to monitor intrathoracic fluid levels using bioimpedance technology, referred to as OptiVol™ Fluid Status Monitoring. Bioimpedance measures, defined as the electrical resistance of tissue to flow of current, are performed many times per day using a vector from the right ventricular coil on the lead in the right side of the heart to the implanted pacemaker devices; changes in bioimpedance reflect intrathoracic fluid status and are evaluated based on a computer algorithm. For example, changes in a patient's daily average of intrathoracic bioimpedance can be monitored; differences in the daily average compared to a baseline are reported as the OptiVol Fluid Index. It has been proposed that these data may be used as an early warning system of cardiac decompensation, or provide additional feedback enabling a physician to further tailor medical therapy. The Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting medical policy addresses the use of external bioimpedance devices as stand-alone devices to noninvasively assess cardiac output.
POLICYBiventricular pacemakers with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD) may be considered medically necessary as a treatment of heart failure in patients who meet all of the following criteria:
NYHA Class III or IV
NYHA class II
*The FDA-labeled indications for QRS duration vary by device. For some devices, FDA approval is based on QRS duration of >130 (eg, InSync® device), while for others, it is based on QRS duration >120 ms (eg, CONTAK CD® CRT-D System). These differences in QRS duration arise from differences in the eligibility criteria in the trials on which the FDA approval is based.
The New York Heart Association (NYHA) functional class is a widely used rating system that quantifies the degree of symptom severity. Each class indicates a value that is reflective of the cardiac functional status. The different functional stages are as follows:
Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD) are considered investigational as a treatment of NYHA class I heart failure.
Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD), are considered investigational as a treatment for heart failure in patients with atrial fibrillation.
An intrathoracic fluid monitoring sensor is considered investigational as a component of a biventricular pacemaker.
Triple-site (triventricular) CRT, using an additional pacing lead, is considered investigational.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/2000: Approved by Medical Policy Advisory Committee (MPAC)
2/8/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
8/2002: Reviewed by MPAC; investigational status changed to medically necessary
12/16/2002: New York Heart Association (NYHA) functional class added, Code Reference section updated, CPT code 33224, 33225, 33226, 33999 added, ICD-9 diagnosis code 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.9 added
3/4/2003: CPT code 33215 added
8/29/2003: "Description" section updated to be consistent with BCBSA
8/9/2005: Code Reference section updated, CPT code 33215, 33999 deleted, ICD-9 procedure code 00.52 added
9/13/2006: Coding revised. ICD9 2006 revisions added to policy
12/13/2006: Policy reviewed, intrathoracic fluid monitoring noted to be investigational
2/19/2008: Policy reviewed, no changes
01/14/2010: Description section updated, Policy Statement was updated to include that biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD) may be considered medically necessary based on indications. Also corrected typographic error, changed QRS duration from >20 msec to >120 msec. Added that biventricular pacemakers with or without an accompanying implantable cardiac defibrillator are considered investigational as a treatment of NYHA class I or II heart failure. Coding Section updated to add the following verbiage: "*Some covered procedure codes may have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section." removed ICD-9 Procedure code 00.52 and added "unspecified" to ICD-9 diagnosis codes 428.0 and 428.9 description.
04/28/2010: Policy description updated to add link to related medical policy. Clarified the policy statement regarding biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator; intent unchanged. Deleted outdated references from the Sources section.
08/03/2011: Policy statement revised to add specific coverage criteria for NYHA class II heart failure. Deleted "congestive" from the policy title and statement.
07/12/2012: Added Cardiac Resynchronization Therapy to the policy title. Deleted "(or angiotensin receptor blocker)" from the fourth bullet after beta blocker in both of the NYHA criteria lists. Added "sinus rhythm" to the class III or IV statement for clarity purposes.
09/25/2012: Added the following investigational policy statement: Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD), are considered investigational as a treatment for heart failure in patients with atrial fibrillation.
05/06/2013: Added the following investigational policy statement: Triple-site (triventricular) CRT, using an additional pacing lead, is considered investigational.
07/16/2014: Policy reviewed; description updated regarding devices. Revised policy statement to state that the FDA-labeled indications for QRS duration vary by device. For some devices, FDA approval is based on QRS duration of >130 (eg, InSync® device), while for others, it is based on QRS duration >120 ms (eg, CONTAK CD® CRT-D System). These differences in QRS duration arise from differences in the eligibility criteria in the trials on which the FDA approval is based.
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 33224 and 33225.
08/21/2015: Code Reference section updated for ICD-10.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.02.10
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.