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DESCRIPTIONA ventricular assist device (VAD) is a mechanical support attached to the native heart and vessels to augment cardiac output. The total artificial heart (TAH) replaces the native ventricles and is attached to the pulmonary artery and aorta; the native heart is typically removed. Both the VAD and TAH may be used as a bridge to heart transplantation or as destination therapy in those who are not candidates for transplantation. The VAD has also been used as a bridge to recovery in patients with reversible conditions affecting cardiac output.
Heart failure may be the consequence of a number of differing etiologies, including ischemic heart disease, cardiomyopathy, congenital heart defects, or rejection of a heart transplant. The reduction of cardiac output is considered to be severe when systemic circulation cannot meet the body’s needs under minimal exertion. Heart transplantation improves quality of life and has survival rates at 1, 5, and 10 years of 88%, 74%, and 55%, respectively. The supply of donor organs has leveled off, while candidates for transplants are increasing, compelling the development of mechanical devices.
Initial research into mechanical assistance for the heart focused on the total artificial heart, a biventricular device which completely replaces the function of the diseased heart. An internal battery required frequent recharging from an external power source. Many systems utilize a percutaneous power line, but a transcutaneous power-transfer coil allows for a system without lines traversing the skin, possibly reducing the risk of infection. Because the heart must be removed, failure of the device is synonymous with cardiac death.
Ventricular assist devices. Implantable ventricular assist devices are attached to the native heart, which may have enough residual activity to withstand a device failure in the short term. In reversible conditions of heart failure, the native heart may regain some function, and weaning and explanting of the mechanical support system after months of use has been described. Ventricular assist devices can be classified as internal or external, electrically or pneumatically powered, and pulsatile or continuous flow. Initial devices were pulsatile, mimicking the action of a beating heart. More recent devices may utilize a pump which provides continuous flow. Continuous devices may move blood in rotary or axial flow.
Surgically-implanted ventricular assist devices represent a method of providing mechanical circulatory support for patients not expected to survive until a donor heart becomes available for transplant or for whom transplantation is otherwise contraindicated or unavailable. They are most commonly used to support the left ventricle, but right ventricular and biventricular devices may be used. The device is larger than most native hearts, and therefore the size of the patient is an important consideration: the pump may be implanted in the thorax or abdomen or remain external to the body. Inflow to the device is attached to the apex of the failed ventricle, while outflow is attached to the corresponding great artery (aorta for left ventricle, pulmonary artery for right ventricle). A small portion of ventricular wall is removed for insertion of the outflow tube; extensive cardiotomy affecting the ventricular wall may preclude VAD use.
Percutaneous ventricular assist devices (pVAD). Devices in which the majority of the system’s components are external to the body are for short-term use (6 hours to 14 days) only, due to the increased risk of infection and need for careful, in-hospital monitoring. Some circulatory assist devices are placed percutaneously, i.e., are not implanted. These may be referred to as percutaneous VADs. The pVADs are placed through the femoral artery. Two different pVADs have been developed, the TandemHeart™ (Cardiac Assist™, Pittsburgh, PA), and the Impella® device (AbioMed™, Aachen, Germany). In the TandemHeart™ system, a catheter is introduced through the femoral artery and passed into the left atrium via transseptal puncture. Oxygenated blood is then pumped from the left atrium into the arterial system via the femoral artery. The Impella device is also introduced through a femoral artery catheter. In this device, a small pump is contained within the catheter that is placed into the left ventricle. Blood is pumped from the left ventricle, through the device, and into the ascending aorta. Adverse events associated with pVAD include access site complications such as bleeding, aneurysms, or leg ischemia. Cardiovascular complications can also occur, such as perforation, myocardial infarction (MI), stroke, and arrhythmias.
There are several situations in which pVAD may offer possible benefits: 1) cardiogenic shock that is refractory to medications and intra-aortic balloon pump (IABP), 2) cardiogenic shock, as an alternative to IABP, and 3) high-risk patients undergoing invasive cardiac procedures who need circulatory support.
Intra-aortic balloon pumps are outside the scope of this policy.
Total Artificial Heart
In October 2004, device CardioWest™ Temporary Total Artificial Heart (SynCardia Systems, Inc., Tucson, AZ) was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process for use as a bridge to transplant in cardiac transplant-eligible candidates at risk of imminent death from biventricular failure. Also, the temporary CardioWest™ Total Artificial Heart (TAH-t) is intended for use inside the hospital. In April 2010, the FDA approved a name-change to Syncardia Temporary Total Artificial Heart.
In September 2006, device AbioCor® Implantable Replacement Heart System (AbioMed, Inc., Danvers MA) was approved by the FDA through the Humanitarian Device Exemption (HDE) process for use in severe biventricular end-stage heart disease individuals who are not cardiac transplant candidates and who:
In addition to meeting other criteria, patients who are candidates for the AbioCor® TAH must undergo a screening process to determine if their chest volume is large enough to hold the device. The device is too large for approximately 90% of women and for many men. The FDA is requiring the company to provide a comprehensive patient information package to patients and families. To further refine and improve the use of this artificial heart technology, AbioMed will conduct a postmarketing study of 25 additional patients. The postmarketing study was recommended by the Circulatory Systems Devices Panel, a part of the FDA's Medical Devices Advisory Committee.
Ventricular Assist Devices
In December 1995, device Thoratec® Ventricular Assist Device System (Thoratec Corp., Pleasanton, CA) was approved by the FDA through the premarket approval process for use as a bridge to transplantation in patients suffering from end-stage heart failure. The patient should meet all of the following criteria:
1) candidate for cardiac transplantation,
2) imminent risk of dying before donor heart procurement, and
3) dependence on, or incomplete response to, continuous vasopressor support.
In May 1998, supplemental approval for the above device was given for the indication for postcardiotomy patients who are unable to be weaned from cardiopulmonary bypass. In June 2001, supplemental approval was given for a portable external driver to permit excursions within a 2-hour travel radius of the hospital in the company of a trained caregiver. In November 2003, supplemental approval was given to market the device as Thoratec® Paracorporeal VAD. In August 2004, supplemental approval was given to a modified device to be marketed as the Thoratec® Implantable VAD for the same indications. In January 2008, supplemental approval was given to delete Paracorporeal VAD use.
In February 2004, the FDA approved the DeBakey VAD® Child under the HDE approval process. According to the FDA, this device is indicated under HDE for both home and hospital use for children who are between ages 5 and 16 years and who have end-stage ventricular failure requiring temporary mechanical blood circulation until a heart transplant is performed.
In April 2008, continuous flow device HeartMate II® LVAS (Thoratec, Pleasanton, CA) was approved by the FDA through the premarket approval process for use as a bridge to transplantation in cardiac transplant candidates at risk of imminent death from nonreversible left ventricular failure. The Heartmate II LVAS is intended for use both inside and outside the hospital. In January 2010, the device received the added indication as destination therapy for use in patients with New York Heart Association (NYHA) Class IIIB or IV end-stage left ventricular failure who have received optimal medical therapy for at least 45 of the last 60 days and are not candidates for cardiac transplantation.
In October 2008, device Centrimag® Right Ventricular Assist Device (Levitronix, Zurich) was approved by the FDA under the HDE to provide temporary circulatory support for up to 14 days for patients in cardiogenic shock due to acute right-sided heart failure.
In December 2012, FDA approved the Heartware® Ventricular Assist System (HeartWare Inc., Miami Lakes, FL) through the PMA. The device is approved as a bridge to cardiac transplantation in patients at risk for death, for patients at risk for death from refractory end-stage left ventricular heart failure.
Percutaneous Ventricular Assist Devices (circulatory assist devices)
The Impella® Recover LP 2.5 Percutaneous Cardiac Support System (Abiomed, Aachen, Germany) received FDA 510(k) approval in May 2008 for short-term (less than six hours) use in patients requiring circulatory support. The TandemHeart® (Cardiac Assist, Pittsburgh) received a similar 510(k) approval for short-term circulatory support in September 2005.
POLICYNo benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.
Postcardiotomy Setting/Bridge to Recovery
Implantable ventricular assist devices with FDA approval or clearance may be considered medically necessary in the post-cardiotomy setting in patients who are unable to be weaned off cardiopulmonary bypass.
Bridge to Transplantation
Implantable ventricular assist devices with FDA approval or clearance may be considered medically necessary as a bridge to heart transplantation for patients who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation.
Implantable ventricular assist devices with FDA approval or clearance, including humanitarian device exemptions, may be considered medically necessary as a bridge to heart transplantation in children 16 years old or younger who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation.
Total artificial hearts with FDA-approved devices may be considered medically necessary as a bridge to heart transplantation for patients with biventricular failure who have no other reasonable medical or surgical treatment options, who are ineligible for other univentricular or biventricular support devices, and are currently listed as heart transplantation candidates or are undergoing evaluation to determine candidacy for heart transplantation, and not expected to survive until a donor heart can be obtained.
Implantable ventricular assist devices with FDA approval or clearance may be considered medically necessary as destination therapy with end-stage heart failure who are ineligible for human heart transplant and who meet the following “REMATCH Study” criteria*:
In addition, patients must not be candidates for human heart transplant for 1 or more of the following reasons:
Other applications of implantable left ventricular devices or total artificial hearts are considered investigational, including, but not limited to, the use of total artificial hearts as destination therapy. The use of non-FDA approved or cleared implantable ventricular assist devices or total artificial hearts is considered investigational.
Percutaneous ventricular assist devices (pVADs) are considered investigational for all indications.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESOnly two ventricular assist devices (VADs) have approval from the U.S. Food and Drug Administration (FDA) for the pediatric population. The DeBakey VAD® Child device and the Berlin Heart EXCOR Pediatric VAD have FDA approval through the humanitarian device exemption (HDE) process. The DeBakey VAD is indicated for use in children ages 5 to 16 years who are awaiting a heart transplant, i.e., as a bridge to transplant while the Berlin Heart EXCOR VAD is indicated for children with severe isolated left ventricular or biventricular dysfunction who are candidates for cardiac transplant and require circulatory support.
In general, candidates for bridge-to-transplant implantable ventricular assist devices (VADs) are those who are considered appropriate heart transplant candidates but who are unlikely to survive the waiting period until a human heart donor is available. Some studies have included the following hemodynamic selection criteria: either a left atrial pressure of 20 mm Hg or a cardiac index of <2.0 L/min/m while receiving maximal medical support. Patients with VADs are classified by the United Network for Organ Sharing (UNOS) as Status I, that is, persons who are most ill and are considered the highest priority for transplant.
The median duration for time on the device is between 20 and 120 days.
Contraindications for bridge to transplant VADs and TAH include conditions which would generally exclude patients for heart transplant. Such conditions are chronic irreversible hepatic, renal, or respiratory failure; systemic infection; coagulation disorders, and inadequate psychosocial support. Due to potential problems with adequate function of the ventricular assist device (VAD) or TAH, implantation is also contraindicated in patients with uncorrected valvular disease. See the Heart Transplant policy for further discussion of heart transplant candidacy.
In addition, individuals must have sufficient space in the thorax and/or abdominal cavity for the device. In the case of the CardioWest™ temporary Total Artificial Heart, this excludes individuals with body surface areas less than 1.7 m2 or who have a distance between the sternum and 10th anterior rib of less than 10 cm as measured by CT [computed tomography] scan.
Investigative 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
3/2003: Reviewed by MPAC; Policy title "Ventricular Assist Devices as a Bridge to Heart Transplantation" renamed "Ventricular Assist Devices", LVAD as a "destination" therapy considered investigational. FEP exception added
7/24/2003: Code References section updated, ICD-9 procedure code 37.61 deleted, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 added covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 added non-covered codes
3/2004: Reviewed by MPAC, coverage remains as written with policy statement added to limit medically necessary indications to FDA approved ventricular assist devices, total artificial hearts are considered investigational, Policy title “Ventricular Assist Devices” renamed “Ventricular Assist Devices and Total Artificial Hearts", Description section revised to be consistent with BCBSA policy # 7.03.11, FEP exceptions added, Sources added, “contraindications” moved from Policy to Policy Guidelines section
10/13/2004: Code Reference section updated, CPT code 0048T, 0049T, 0050T added covered codes, CPT 33975, 33976, 33977, 33978 description revised, ICD-9 procedure code 37.62, 37.63, 37.66 description revised, ICD-9 procedure code 37.68 added, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 deleted covered codes, CPT 0051T, 0052T, 0053T added non-covered codes, ICD-9 procedure code 37.52, 37.53, 37.54 added non-covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 deleted non-covered codes
11/11/2005: Code Reference section updated, HCPCS codes Q0480-Q0505 added
4/10/2006: Policy reviewed, no change to policy. Q0480-Q0505 already added to policy
9/6/2006: Policy updated to include information on the AbioCor artificial heart
9/18/2006: Coding revised. ICD9 2006 revisions added to policy.
5/7/2008: Policy description updated. Total artificial hearts changed from investigational to medically necessary for FDA-approved devices as a bridge to heart transplantation. Ventricular assist devices as destination therapy with end-stage heart failure changed from investigational to medically necessary for FDA-approved devices in patients ineligible for human heart transplant. Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts.
03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section.
12/13/2011: Policy description and statement updated regarding percutaneous ventricular assist devices. Added the following policy statement: Percutaneous ventricular assist devices (pVADs) are considered investigational for all indications.
11/30/2012: Added the verbiage "or are undergoing evaluation to determine candidacy for heart transplantation" to the policy statement regarding total artificial hearts.
01/07/2013: Added the following new 2013 CPT codes to the Code Reference section: 33990, 33991, 33992, and 33993.
07/18/2013: Policy statement revised to delete Peak O-2 consumption ≤14 ml/kg criteria from the policy statement regarding “REMATCH Study.” Policy guidelines updated regarding available devices and candidate selection.
05/23/2014: Added "Implantable" to the policy title. Policy description updated regarding available devices. Added the following headings to the policy statement: Postcardiotomy Setting/Bridge to Recovery, Bridge to Transplantation, Destination Therapy, and Other Indications. Replaced "cleared devices" with "clearance." Added "Implantable" to the beggining of the policy statement under the Bridge to Transplantation section. Policy statement on implantable VADs as a bridge to heart tranplantation in children was revised to change the age range from "5 to 16" to "16 years old or younger," reflecting the approval of the BERLIN heart EXCOR device for pediatric patients. Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section.
07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.03.11
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.