Cardiac Resynchronization Therapy and Other Pacing/Defibrillator Treatments for Heart Failure (CPB 0610, reviewed 2026-09-18)

IMMEDIATELY: Billing team must implement new prior authorization and medical necessity verification protocols for cardiac resynchronization therapy claims. (1) Update billing software to enforce documentation requirements: For CPT 33208, 33213, 33214, 33224, 33225, 33230, 33231, 33240, and HCPCS G0448, C7537-C7540 — require provider submission of NYHA functional classification (II-IV), LVEF measurement ≤35%, QRS duration documentation, and proof of 3+ months optimal pharmacologic therapy (ACE inhibitor, ARB, beta blocker, digoxin, or diuretic). (2) For combination resynchronization-defibrillator devices, additionally require documentation of one of: prior cardiac arrest from ventricular tachyarrhythmias, sustained VT, prior MI with non-sustained VT, or LVEF ≤30%. (3) DENY all claims for CPT codes 0515T-0522T (wireless cardiac stimulation), CPT 82777 (galectin-3), and HCPCS C1882 claims lacking high-risk criteria — these are experimental/investigational. (4) Update encounter forms and clinical documentation templates to include fields for NYHA classification, LVEF values, QRS duration, and cardiac medication list. (5) Providers and pre-authorization staff must be trained on policy requirements immediately. (6) Implement automated claim holds for missing documentation; claims will be denied without proper medical necessity documentation per Aetna guidelines.