ICD-10 Z95.811 is officially defined as "Presence of heart assist device." code Z95.811 is referenced in 8 tracked payer policy changes from Florida Blue, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z95.811 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Florida Blue has issued updated coding guidelines for Congestive Heart Failure (CHF) documentation and ICD-10 coding. The policy emphasizes specific documentation requirements for HF type, acuity, ejection fraction, and proper use of ICD-10 codes I50.2- through I50.84 to ensure accurate risk stratification and reimbursement.
Aetna Clinical Policy Bulletin 0654 covers ventricular assist devices (VADs) and sets the criteria under which Aetna considers them medically necessary. A VAD is medically necessary as a bridge to transplant when the device has FDA approval for that indication and the member is awaiting heart transplantation. A VAD for destination therapy requires NYHA Class IV end-stage ventricular heart failure, a member who is not a candidate for heart transplant, an LVEF less than 25%, and the medical management and peak oxygen consumption criteria listed in the policy. Percutaneous VADs such as the TandemHeart and Impella are medically necessary for short-term circulatory support in cardiogenic shock and for listed high-risk PCI situations, and VADs are considered experimental, investigational, or unproven for all other indications.
Aetna considers an FDA-approved ventricular assist device medically necessary as a bridge to transplant when the device has FDA approval for that indication, and as destination therapy when all of the listed criteria are met: NYHA Class IV end-stage heart failure, not a candidate for heart transplant, failure to respond to optimal medical management for at least 45 of the last 60 days (or balloon pump dependence for 7 days, or IV inotrope dependence for 14 days), LVEF less than 25%, and peak oxygen consumption less than or equal to 14 mL/kg/min. Percutaneous VADs such as the TandemHeart and the Impella are medically necessary for short-term circulatory support in cardiogenic shock and as an adjunct to high-risk PCI in the listed scenarios, and short-term LVADs, RVADs or BiVADs such as the CentriMag are medically necessary for up to 30 days in post-cardiotomy or refractory acute cardiogenic shock when the member is willing and able to be treated with heparin or an appropriate alternative anticoagulant. VADs are considered experimental, investigational or unproven for all other indications, including concomitant mitral valve surgery with LVAD implantation for mitral regurgitation, pVADs during ablation of ventricular tachycardia, implantable aortic counterpulsation ventricular assist systems, and use of mesenchymal precursor cells as adjunctive therapy in VAD recipients.
Aetna's Cardioverter-Defibrillators policy (CPB 0585, last review 04/22/2026) covers FDA-approved implantable cardioverter-defibrillators for members with listed indications, including spontaneously occurring ventricular fibrillation or sustained ventricular tachycardia not associated with acute myocardial infarction, and ischemic or non-ischemic dilated cardiomyopathy with NYHA class II or III heart failure and an LVEF of 35% or less on optimal medical therapy. Extravascular and subcutaneous defibrillators and wearable or non-wearable cardioverter-defibrillators are covered only under the criteria stated, while ICDs with hemodynamic monitoring, use in persons with left ventricular assist devices, and N-terminal pro-B type natriuretic peptide testing for prognosis of ICD implantation are listed as experimental, investigational or unproven.
Aetna considers intensive cardiac rehabilitation programs (the Benson-Henry Institute Cardiac Wellness Program, the Ornish cardiac treatment program and the Pritikin Program) medically necessary as an alternative to traditional Phase II cardiac rehabilitation for members who meet the cardiac rehabilitation criteria, limited to 72 one-hour sessions, up to 6 per day, over a period of up to 18 weeks. Virtual delivery by real-time audio and video (excluding audio-only) is considered medically necessary when the telehealth program and member criteria are met, but hospital outpatient departments are not eligible for virtual telehealth services. Intensive cardiac rehabilitation is considered experimental, investigational or unproven for diabetes, hyperlipidemia, prostate cancer, metabolic syndrome and all other indications where effectiveness has not been established.
Aetna considers transcranial Doppler ultrasonography medically necessary for indications including assessing collateral blood flow and embolization during carotid endarterectomy, evaluating persons with suspected brain death, detecting microemboli after stroke or transient ischemic attack, evaluating giant cell arteritis, and assessing stroke risk in children aged 2 to 16 years with sickle cell anemia. Aetna considers it experimental, investigational, or unproven for all other indications, including screening for carotid artery stenosis in asymptomatic adults, managing traumatic brain injury, migraine headaches, epilepsy, and evaluating adults with sickle cell anemia. The covered CPT codes are 93886, 93888, 93890, 93892, 93893, 93896, 93897 and 93898 when selection criteria are met.
Aetna clinical policy bulletin 0173 considers prothrombin time (INR) home testing units medically necessary durable medical equipment for patients on chronic warfarin for a mechanical heart valve, ventricular assist device, chronic atrial fibrillation, deep venous thrombosis, pulmonary embolism, venous embolism and thrombosis of deep vessels of the lower extremity, or hypercoagulable states, when the expected need for home INR testing is 6 or more months, the patient has been anticoagulated for at least 3 months before using the device, and self-testing does not occur more than once a week. Aetna considers the units experimental, investigational, or unproven for all other indications, including arterial embolism to the eye, atrial flutter, and Kawasaki disease.
At-home prothrombin time (INR) monitoring of chronic warfarin therapy may be considered medically necessary for patients who require continuous anticoagulation for chronic medical conditions, including patients with mechanical heart valves and chronic atrial fibrillation. Before at-home monitoring starts, patients must have undergone anticoagulation management for at least 3 months. The policy history records a 05/04/2026 update that removed ICD-9 diagnosis codes from the Code Reference section and added ICD-10 diagnosis codes Z95.811, Z95.812 and Z95.818. The covered procedure codes are CPT 93792 and HCPCS E1399, G0248, G0249 and G0250.
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