Biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator) may be considered medically necessary as a treatment of heart failure in patients who meet all of the following criteria:
For New York Heart Association class III or IV,
Left ventricular ejection fraction ≤35%
Sinus rhythm
Patients treated with guideline-directed medical therapy (see Policy Guidelines section)
AND
Either left bundle branch block OR QRS interval ≥150 ms.
For New York Heart Association class II,
Left ventricular ejection fraction ≤30%
Sinus rhythm
Patients treated with a guideline-directed medical therapy (see Policy Guidelines section)
AND
Either left bundle branch block OR QRS interval ≥150 ms.
For patients who do not meet the criteria outlined above, but have an indication for a ventricular pacemaker or biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker/implantable cardiac defibrillator) may be considered medically necessary asan alternative to a right ventricular pacemaker in patients who meet all of the following criteria:
New York Heart Association class I, II, III, or IV heart failure;
Left ventricular ejection fraction ≤50%;
The presence of atrioventricular block with requirement for a high percentage of ventricular pacing (see Policy Guidelines section); and
Patients treated with guideline-directed medical therapy (see Policy Guidelines section).
Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator), are considered investigational as a treatment for patients with New York Heart Association class I heart failure who do not meet the above criteria.
Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator), are considered investigational as a treatment for heart failure in patients with atrial fibrillation who do not meet the above criteria.
Triple-site (triventricular) cardiac resynchronization therapy, using an additional pacing lead, is considered investigational.
An intrathoracic fluid monitoring sensor is considered investigational as a component of a biventricular pacemaker.
Cardiac resynchronization therapy with wireless left ventricular endocardial pacing is considered investigational.
