All PlansCoverageMedium impact
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Blue Cross & Blue Shield of Mississippi·MS · Cardiology, Cardiothoracic Surgery·Medical Policy
We identified it
Jun 20, 2026
Summary
This policy establishes medical necessity criteria for biventricular pacemakers (cardiac resynchronization therapy) for heart failure treatment. Coverage requires specific NYHA class, ejection fraction, rhythm, and QRS criteria that must be met and documented for claim approval.
Action Required
Immediately: Billing team must ensure proper documentation of NYHA class, left ventricular ejection fraction, sinus rhythm status, QRS interval measurements, and guideline-directed medical therapy compliance for all biventricular pacemaker claims. Update prior authorization workflows to verify patients meet specific criteria: NYHA III/IV with EF <35% OR NYHA II with EF ≤30%, plus either left bundle branch block or QRS ≥150ms. Claims not meeting these criteria will likely be denied.