Medicare AdvantageCoverageMedium impact
Cardiac Pacemakers - Medicare Advantage (Revised)
Humana·Cardiology, Cardiothoracic Surgery·Medicare Advantage
Effective date
Nov 2, 2026
We identified it
Oct 28, 2026
Summary
Humana revised its Medicare Advantage cardiac pacemaker coverage policy effective 11/02/2026, updating medical necessity criteria for permanent pacemakers and leadless pacemakers. The policy now references current CMS NCDs and LCDs by jurisdiction and specifies coverage criteria for single/dual chamber permanent pacemakers, leadless pacemakers, and pacemaker monitoring services.
Action Required
By 2026-11-02: Billing team must update clinical documentation requirements and prior authorization workflows to align with revised permanent and leadless pacemaker coverage criteria in this policy. Verify that pacemaker implant and removal/replacement requests (CPT 33206-33214, 33221, 33227-33229, 33233-33235, 0795T-0804T, 0824T-0826T, and HCPCS C-codes) are reviewed against the specific medical necessity indications listed in the policy before claim submission. Confirm that requests reference applicable CMS NCDs 20.8.1-20.8.4 and the appropriate MAC-specific LCAs based on geographic jurisdiction. Update internal billing documentation to track which indication(s) support each case to ensure compliance with Medicare Advantage coverage rules. Failure to align with these criteria may result in claim denials or post-payment recovery requests.