CommercialCoverageMedium impact
Leadless Cardiac Pacemaker (CPB 0893, reviewed 2025-12-22)
Aetna·Cardiology, Cardiothoracic Surgery, Internal Medicine·Medical Policy
Effective date
Dec 22, 2025
We identified it
Aug 17, 2026
Summary
Aetna has issued a new clinical policy (CPB 0893, effective 2025-12-22) establishing coverage criteria for FDA-approved leadless cardiac pacemakers. Coverage is limited to patients with specific cardiac conduction disorders AND significant contraindications to conventional pacemakers. Combination therapies (leadless pacemaker with CRT or ICD) remain experimental/non-covered. Billing teams must verify medical necessity against strict criteria before submitting claims.
Action Required
By December 22, 2025: (1) Billing team must update system edits to require documentation of BOTH conditions before allowing claims for CPT codes 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0823T, 0824T, 0825T, 0826T, 33274, 33275, and related programming/interrogation codes (93279, 93286, 93288, 93294, 93296). (2) Providers must document: (a) symptomatic paroxysmal or permanent high-grade AV block, symptomatic bradycardia-tachycardia syndrome, OR sinus node dysfunction; AND (b) one of three contraindications: prior CIED infection/high risk, venous access limitations, or bio-prosthetic tricuspid valve. (3) Flag all claims for combination leadless pacemaker + CRT or + subcutaneous ICD (no specific CPT code exists yet) as non-covered/experimental. (4) Update clinical documentation requirements in EMR and encounter forms to capture required medical necessity elements. Claims submitted without proper documentation of both criteria will be denied. Consequence: Denial of payment and potential rework costs.