Aetna · Identified Aug 15, 2026Medium impact
Cardiac Resynchronization Therapy and Other Pacing/Defibrillator Treatments for Heart Failure (CPB 0610, reviewed 2025-12-02)
Aetna considers FDA-approved biventricular pacemakers (cardiac resynchronization therapy) medically necessary for members with congestive heart failure who are in sinus rhythm when either NYHA class III or IV with LVEF less than or equal to 35%, QRS duration greater than or equal to 150 msec, and an optimal pharmacologic regimen of 3 months of maximally titrated doses as tolerated before implantation are met, or at least 40 days post myocardial infarction; or when NYHA class II to IV with LVEF less than or equal to 35%, left bundle branch block with QRS duration greater than or equal to 130 msec, and the same regimen or at least 40 days post MI are met. Aetna considers combination resynchronization-defibrillator devices medically necessary for members at high risk for sudden cardiac death when those criteria are met and at least one of the following applies: at least 1 episode of cardiac arrest from ventricular tachyarrhythmias, recurring poorly tolerated sustained ventricular tachycardia, a prior heart attack with documented non-sustained ventricular tachycardia and an inducible ventricular tachyarrhythmia, or a prior heart attack with LVEF less than or equal to 30%. Aetna considers left bundle branch pacing medically necessary when cardiac resynchronization therapy is indicated and left ventricular pacing cannot be accomplished, and considers biventricular pacing for atrial fibrillation, mild heart failure (NYHA class I), and anti-bradycardia pacing, wireless left ventricular endocardial pacing, His bundle pacing for cardiac resynchronization therapy, the galectin-3 test, and implantable diaphragmatic stimulation (VisCardia's VisONE system) experimental, investigational, or unproven.