CommercialCoverageHigh impact
Cardiac Resynchronization Therapy and Other Pacing/Defibrillator Treatments for Heart Failure (CPB 0610, reviewed 2025-12-02)
Aetna·Cardiology, Cardiothoracic Surgery, Critical Care +1 more·Medical Policy
Effective date
Dec 2, 2025
We identified it
Aug 15, 2026
Summary
Aetna updated its cardiac resynchronization therapy (CRT) and pacing/defibrillator policy (CPB 0610) effective 2025-12-02, clarifying medical necessity criteria for biventricular pacemakers, combination resynchronization-defibrillator devices, and left bundle branch pacing in heart failure patients. The policy explicitly designates certain procedures as experimental/investigational (wireless LV endocardial pacing, His bundle pacing, Galectin-3 testing for CRT selection, and implantable diaphragmatic stimulation), which will require claim denials or prior authorization adjustments.
Action Required
By December 2, 2025: (1) Billing team must update claim submission rules in billing software to DENY or require prior authorization for experimental codes: 0515T-0522T (wireless CRT), 82777/83520 (Galectin-3 testing). These are no longer covered for CRT selection. (2) Billing team must verify that all CRT claims (CPT 33208, 33213, 33214, 33224, 33225, 33230, 33231, 33240, 33249, 33262) include documentation of medical necessity meeting EITHER criterion A (NYHA III/IV + LVEF ≤35% + QRS ≥150ms + optimal meds + 40+ days post-MI) OR criterion B (NYHA II-IV + LVEF ≤35% + LBBB with QRS ≥130ms + optimal meds + 40+ days post-MI). (3) For combination resynchronization-defibrillator devices, ensure claims include documentation of high sudden cardiac death risk (prior cardiac arrest, sustained VT, or post-MI with LVEF ≤30%). (4) Update prior authorization templates to clarify that left bundle branch pacing is only approved when LV pacing cannot be accomplished. (5) Cardiology providers must update documentation practices to explicitly state medication regimen used for 3+ months pre-implant and days post-MI. (6) Reject any claims for CRT in atrial fibrillation patients or NYHA Class I (mild) heart failure—these are experimental and not covered. Failure to implement will result in claim denials and potential recoupment.