CommercialCoverageHigh impact
Ventricular Assist Devices (CPB 0654, reviewed 2026-09-10)
Aetna·Cardiology, Cardiothoracic Surgery, Critical Care +2 more·Medical Policy
We identified it
Oct 5, 2026
Summary
Aetna updated its Ventricular Assist Device (VAD) medical policy (CPB 0654) with clarified coverage criteria for FDA-approved devices across multiple indications including bridge to transplant, destination therapy, refractory electrical storm, percutaneous VADs, pediatric VADs, temporary circulatory support, and the Impella RP System. The policy explicitly identifies which procedures and devices are experimental/investigational (including aortic counter-pulsation systems and concomitant mitral valve surgery with LVAD). Billing teams must verify member eligibility against specific clinical criteria (NYHA Class IV, LVEF <25%, peak VO2 ≤14 mL/kg/min, etc.) before processing claims.
Action Required
IMMEDIATELY: Billing team must update authorization and adjudication workflows to reflect Aetna's VAD coverage criteria. SPECIFIC ACTIONS: (1) For CPT 33975-33983 (implantable/extracorporeal VADs): Verify member meets destination therapy criteria—NYHA Class IV, LVEF <25%, peak VO2 ≤14 mL/kg/min, failed optimal medical management for ≥45 of last 60 days OR balloon pump dependent ≥7 days OR IV inotrope dependent ≥14 days. (2) For CPT 33990-33993 (percutaneous VADs): Confirm indication is cardiogenic shock OR high-risk PCI (unprotected left main with EF <35%, last-remaining-conduit with EF <35%, or three-vessel disease with EF <30%). (3) For pediatric VADs: Verify documented end-stage left ventricular failure and size-appropriate device selection. (4) DO NOT COVER CPT 0451T-0463T (aortic counter-pulsation systems like NuPulseCV iVAS, Symphony Heart Assist System)—these are experimental and require denial with explanation. (5) DO NOT COVER concomitant mitral valve surgery with LVAD implantation (experimental). (6) For Impella RP (percutaneous right heart support): Limit authorization to 14 days for members with BSA ≥1.5 m² following LVAD implantation, MI, heart transplant, or open-heart surgery. Update billing system rules in prior authorization module, encounter templates, and denial reason codes. Front-office staff should request clinical documentation supporting medical necessity before claim submission. Failure to verify criteria will result in claim denials and patient balance issues. Distribute policy summary to providers immediately.