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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-33000-25

Original Effective Date: 01/01/02

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Ventricular Assist Devices and Total Artificial Hearts

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Heart failure may be the consequence of a number of differing etiologies, including ischemic heart disease, cardiomyopathy, congenital heart defects, or rejection of a heart transplant. The reduction of cardiac output is considered to be severe when systemic circulation cannot meet the body’s needs under minimal exertion. Heart transplantation improves quality of life and survival. The U.S. Organ Procurement and Transplantation Network (OPTN) reports survival rates at 1-, 5-, and 10-years of 88%, 74%, and 55%, respectively. The supply of donor organs has leveled off, while candidates for transplants are increasing, compelling the development of mechanical devices.

The New York Heart Association (NYHA) developed a functional classification for patients with heart disease. Each of the four classifications are described in the table below:

Class I (mild)

Has no limitations on clinical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

Class II (mild)

Has slight limitations of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Class III (moderate)

Has marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Class IV (severe)

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Ventricular Assist Devices

Implantable ventricular assist devices are attached to the native heart, which may have enough residual activity to withstand a device failure in the short term. In reversible conditions of heart failure, the native heart may regain some function, and weaning and explanting of the mechanical support system after months of use has been described. VADs can be classified as internal or external, electrically or pneumatically powered, and pulsatile or continuous flow. Initial devices were pulsatile, mimicking the action of a beating heart. More recent devices may use a pump, which provides continuous flow. Continuous flow devices may move blood in rotary or axial flow.

At least one VAD system has been developed that is miniaturized and generates an artificial pulse, the HeartMate 3 LVAS.

Surgically-implanted ventricular assist devices represent a method of providing mechanical circulatory support for individuals not expected to survive until a donor heart becomes available for transplant or for whom transplantation is otherwise contraindicated or unavailable. Ventricular assist devices are most commonly used to support the left ventricle, but right ventricular and biventricular devices may be used. The device is larger than most native hearts, and therefore the size of the candidate is an important consideration: the pump may be implanted in the thorax or abdomen or remain external to the body. Inflow to the device is attached to the apex of the failed ventricle, while outflow is attached to the corresponding great artery (aorta for left ventricle, pulmonaryartery for right ventricle). A small portion of ventricular wall is removed for insertion of the outflow tube; extensive cardiotomy affecting the ventricular wall may preclude ventricular assist device use.

Percutaneous Ventricular Assist Devices

Devices in which most of the system’s components are external to the body are for short-term use (6 hours to 14 days) only, due to the increased risk of infection and need for careful, in-hospital monitoring. Some circulatory assist devices are placed percutaneously (ie, are not implanted). These may be referred to as pVADs. pVADs are placed through the femoral artery. There are several situations in which pVADs may offer possible benefits: (1) cardiogenic shock that is refractory to medications and IABP, (2) cardiogenic shock, as an alternative to IABP, and (3) high-risk patients undergoing invasive cardiac procedures who need circulatory support.

Right Ventricular Assist Devices

Right ventricular assist devices are intended to provide temporary circulatory support for up to fourteen days for persons in cardiogenic shock due to acute right ventricular failure. The device is contraindicated in those who are unable or unwilling to be treated with heparin or an appropriate alternative anticoagulation. Although right ventricular heart failure is infrequent, it may occur following cardiac surgery, myocardial infarction (MI), heart transplantation, or implantation of a left ventricular assist device. Right ventricular assist devices receive blood from either the right atrium or right ventricle and deliver it to the pulmonary artery, via an inflow cannula placed in either the right atrium (RA) or right ventricle.

Total Artificial Hearts

Initial research into mechanical assistance for the heart focused on the total artificial heart (TAH), a biventricular device which completely replaces the function of the diseased heart. An internal battery required frequent recharging from an external power source. Many systems use a percutaneous power line, but a transcutaneous power-transfer coil allows for a system without lines traversing the skin, possibly reducing the risk of infection. Because the heart must be removed, failure of the device is synonymous with cardiac death.

A fully bioprosthetic TAH, which is fully implanted in the pericardial sac and is electrohydrolically actuated, has been developed and tested in 2 patients.

POSITION STATEMENT:

Ventricular Assist Devices

The use of an FDA-approved or cleared implantable ventricular assist device (VAD) meets the definition of medical necessity:

• As a bridge to heart transplantation for:

o Members who are currently listed as heart transplant candidates, OR

o Are undergoing evaluation to determine candidacy for heart transplant, AND

o Are not expected to survive until a donor heart can be obtained

• As a bridge to recovery in the post-cardiotomy setting in members who are unable to be weaned off cardiopulmonary bypass.

• As destination therapy when the following criteria are met:

o Member has end stage heart failure, AND

o Member is ineligible for human heart transplant due to one of the following:

- Age > 65 years

- Insulin dependent diabetes mellitus with end-organ damage

- Chronic renal failure (serum creatinine > 2.5 mg/dl for ≥ 90 days

- Presence of other clinically significant condition, AND

o New York Heart Association (NYHA) class IV heart failure for ≥ 60 days, OR

o NYHA class III/IV heart failure for at least 28 days AND

- Received ≥14 days support with intra-aortic balloon pump (IABP), OR

- Dependent on IV inotropic agents, with 2 failed weaning attempts.

The use of an FDA-approved or cleared percutaneous ventricular assist device meets the definition of medical necessity:

• To provide short-term circulatory support for patients with cardiogenic shock

The use of an FDA-approved or cleared right ventricular assist device meets the definition of medical necessity when both of the following are met:

• Device is used for temporary circulatory support for up to thirty days for individuals in cardiogenic shock due to acute right ventricular failure; AND

• Member is willing and able to be treated with heparin or an appropriate alternative anticoagulant

Total Artificial Hearts

The use of an FDA-approved or cleared total artificial heart meets the definition of medical necessity as a bridge to transplantation when all of the following are met:

• Biventricular failure with no other reasonable medical or surgical treatment options; AND

• Ineligible for other univentricular or biventricular support devices; AND

• Currently listed a heart transplant candidate or undergoing evaluation to determine candidacy for heart transplant; AND

• Not expected to survive until a donor heart can be obtained.

Other applications of implantable ventricular devices or total artificial hearts, including the use of total artificial hearts as destination therapy, are considered experimental or investigational. There is insufficient clinical evidence in the peer reviewed literature to allow conclusions on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

33975

Insertion of ventricular assist device; extracorporeal, single ventricular

33976

Insertion of ventricular assist device; extracorporeal, biventricular

33977

Removal of ventricular assist device; extracorporeal single ventricular

33978

Removal of ventricular assist device; extracorporeal biventricular

33979

Insertion of ventricular assist device, implantable intracorporeal, single ventricle

33980

Removal of ventricular assist device, implantable intracorporeal, single ventricle

33981

Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump

33982

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass

33983

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass

33990

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only

33991

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture

33992

Removal of percutaneous ventricular assist device at separate and distinct session from insertion

33993

Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion

0051T

Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy

0052T

Replacement or repair of thoracic unit of a total replacement heart system (artificial heart)

0053T

Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit

0451T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)

0452T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal, aortic counterpulsation device and vascular hemostatic seal

0453T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano-electrical skin interface

0454T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode

0455T

Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes)

0456T

Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal

0457T

Removal of permanently implantable aortic counterpulsation ventricular assist system; mechano-electrical skin interface

0458T

Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode

0459T

Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device,mechano- electrical skin interface and electrodes

0460T

Repositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode

0461T

Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device

0462T

Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day

0463T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day

REIMBURSEMENT INFORMATION:

None applicable.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following National Coverage Determinations (NCD) were reviewed on the last guideline reviewed date: Artificial Hearts and Related Devices (20.9); and Ventricular Assist Devices (20.9.1) located at cms.gov.

DEFINITIONS:

Destination therapy: the use of a ventricular assist device (VAD) for long-term, permanent support in patients who are not candidates for transplant.

Humanitarian Device Exemption (HDE): a device that is intended to benefit patients by treating or diagnosing a disease or condition that affects or is manifested in fewer than 4,000 people in the United States per year.

Inotropic support: medications to help the heart pump more effectively.

Intra-aortic balloon pump: a machine that helps the heart pump; a catheter threaded into the aorta is equipped with a tip that helps pump blood out of the heart; does not require open chest surgery for placement.

RELATED GUIDELINES:

Heart Transplant, 02-33000-23
Heart and Lung transplant, 02-33000-24

OTHER:

Available mechanical circulatory support devices (may not be an all inclusive list)

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Ventricular assist devices

DeBakey VAD® Child: FDA approved as a bridge to transplant in children 5-16 y of age.

HeartMate II®: FDA approved as a bridge to transplant and as destination therapy.

Berlin Heart EXCOR® Pediatric VAD: FDA approved as a bridge to transplant.

HeartWare® Ventricular Assist System: FDA approved as a bridge to transplant.

Percutaneous ventricular assist devices

Impella®: FDA approved to provide partial circulatory support using extracorporeal bypass control unit for periods up to 6 hours, including temporary ventricular support during high-risk percutaneous coronary interventions

TandemHeart®: FDA approved for temporary left ventricular bypass of ≤6 hours.

Total artificial hearts

SynCardia Temporary Total Artificial Heart (formerly CardioWest™ Temporary Total Artificial Heart): FDA approved for use inside the hospital as a bridge to transplant in cardiac transplant-eligible candidates at risk of imminent death from biventricular failure

AbioCor® Implantable Replacement Heart System: FDA approved through the HDE process for use in severe biventricular end stage heart disease patients who are not cardiac transplant candidates and who:

• Are younger than 75 years of age

• Require multiple inotropic support

• Are not treatable by left ventricular assist device (LVAD) destination therapy

• Are not weanable from biventricular support if on such support

Have a chest volume large enough to hold the device as determined by a screening process

Right ventricular assist devices

Centrimag® Right Ventricular Assist Device: FDA approved through the HDE process to provide temporary circulatory support for up to 14 days for patients in cardiogenic shock due to acute right-sided heart failure.

REFERENCES:

  1. All-Plan Survey (Blue Cross Blue Shield), (11/99).
  2. American College of Cardiology. "ACC/AHA Guidelines for the Evaluation and Management of Heart Failure." Published 2001; accessed 05/29/07.
  3. American Medical Association CPT Coding (current edition).
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.03.08 Heart/Lung Transplant, (04/25/06).
  5. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.03.11 Ventricular Assist Devices and total Artificial Hearts. (August 2016).
  6. Blue Cross Blue Shield Association TEC Assessments 1996, 2002.
  7. Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Ventricular Assist Devices (20.9.1) (10/30/13).
  8. Centers for Medicare & Medicaid Services (CMS) National Coverage Determination for Artificial Hearts and Related Devices, Publication #100-3, Section 20.9 (10/30/13).
  9. Centers for Medicare and Medicaid Services (CMS) Decision Memo for Ventricular Assist Devices as Destination Therapy (CAG-00119N); 10/01/03.
  10. Centers for Medicare and Medicaid Services (CMS) Decision Memo for Artificial Hearts (CAG-00322N); 05/01/08.
  11. Cheng JM, Corstiaan A, Hoeks SE, van der Ent M, Jewbali LSD, van Domburg RT, Serruys PW. Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials. European Heart Journal (2009) 30, 2102–2108.
  12. Clinical Trials.gov. Abiocor Implantable Replacement Heart. Verified by Abiomed Inc., April 2008. Identifier: NCT00669357.
  13. ClinicalTrials.gov. SynCardia CardioWest TAH-t Postmarket Surveillance Study. Sponsored by SynCardia. Identifier: NCT00614510.
  14. ClinicalTrials.gov. NCT01415869. Occult Gastrointestinal Bleeding in Non-pulsatile Left Ventricular Assist Device (VAD) Patients. Last Updated on 08/08/11 by Mayo Clinic.
  15. ClinicalTrials.gov. NCT01185691. Investigating the Role of Impella 2.5 System in Acutely Decompensated Chronic Heart Failure Patients (RELIEF I). Last Updated on March 18, 2011 by Abiomed, Inc.
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  28. Cubeddu RJ, MD, Lago R, Horvath SA, Vignola PA, O’Neill W, Palacios IF. Expert Review: Use of the Impella 2.5 system alone, after and in combination with an intra-aortic balloon pump in patients with cardiogenic shock: case description and review of the literature. EuroIntervention 2012; 7:1453-1460.
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  30. ECRI. Target Database Report: Permanent Total Artificial Heart for Irreversible Heart Failure Plymouth meeting PA: ECRI, (06/04).
  31. ECRI. Target Database Report: Permanent Total Artificial Heart (TAH) for Irreversible Heart Failure Plymouth meeting PA: ECRI, (02/08).
  32. ECRI. Target Database Report: Total Artificial Heart as Bridge to Transplantation. Plymouth meeting PA: ECRI (01/07) Updated 02/06/07.
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  34. ECRI. Target Database Report: Ventricular Assist Devices for Heart Failure (long-term to heart transplant) Plymouth meeting PA: ECRI, (02/00).
  35. ECRI. Target Database Report: Ventricular Assist Devices for Heart Failure (short-term bridge to recovery) Plymouth meeting PA: ECRI, (03/00).
  36. ECRI Institute Emerging Technology Evidence Report: Total Artificial Heart as Bridge to Transplantation and Destination Therapy. December 2012.
  37. ECRI Institute Emerging Technology Report: Miniature Intracardiac Pump for Acute Heart Failure. January 2012.
  38. ECRI Institute Health Technology Forecast: More data presented at ACC confirm miniature heart pump failed to meet primary endpoints in trial. April 2011.
  39. Edoardo Gronda, MD, Robert C. Bourge, MD, Maria Rosa Costanzo, MD, Mario Deng, MD, Donna Mancini, MD, Luigi Martinelli, MD, and Guillermo Torre-Amione, MD. Heart Rhythm Considerations in Heart Transplant Candidates and Considerations for Ventricular Assist Devices: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates – 2006. The Journal of Heart and Lung Transplantation. Volume 25, Issue 9, pages 1024 – 1042. September 2006.
  40. Ganyukov V, Tarasov R. High risk percutaneous coronary interventions-significance of left ventricular assist device for clinical practice. J Thorac Dis. 2015 Oct;7(10):1716-8.
  41. Glenn N et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574-e651.
  42. Gregory D et al. A Value-Based Analysis of Hemodynamic Support Strategies for High-Risk Heart Failure Patients Undergoing a Percutaneous Coronary Intervention. Am Health Drug Benefits. 2013;6(2):88-99.
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  44. HAYES Inc. Medical Technology Directory: Total Artificial Heart, temporary or Permanent Biventricular Support Device Lansdale, PA. Hayes Inc. 07/18/05, updated 07/11/07.
  45. HAYES Inc. Medical Technology Directory: Ventricular Assist Devices. Lansdale, PA. Hayes Inc. 05/HAYES Medical Technology Directory: ”Ventricular Assist Devices” 05/06/05, updated 05/11/06.
  46. Hernandez, Arian F., Shea, Alisa M., Milano, Carmelo A.; et al. Long-term Outcomes and Costs of Ventricular Assist Devices Among Medicare Beneficiaries. JAMA. 2008; 300(20):2398-2406.
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  59. Roger VL et al. Executive Summary: Heart Disease and Stroke Statistics--2012 Update : A Report From the American Heart Association. Circulation. 2012;125:188-197.
  60. Rose EA MD, et al. Long-term Use of a Left Ventricular Assist Device for End-Stage Heart Failure”. N Eng J Med 2001; 345(20): 1435 – 1443.
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  62. Saxena P, Marasco SF. Tunneling a Pulmonary Artery Graft: A Simplified Way to Insert and Remove a Temporary Right Ventricular Assist Device. Tex Heart Inst J. 2015 Dec 1;42(6):540-2.
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  65. Slaughter, Mark S., MD, Sobieski, Michael A., CCP, Gallagher, Collen, RN, Dia, Muhyaldeen, MD, Silver, Marc A., MD. Low Incidence of Neurologic Events during Long-Term Support with the HeartMate® XVE Left Ventricular Assist Device. Tex Heart Inst J. 2008; 35(3): 245–249.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

01/01/01

Medical Coverage Guideline developed.

01/01/02

Annual HCPCS coding update.

09/15/03

Reviewed; revised to delete investigational statement regarding VADs used for destination therapy and add coverage criteria for this indication; added new HCPCS codes for VADs; added clarification for VADs vs. artificial heart devices.

08/15/04

Scheduled review; revised title to include total artificial hearts; added procedure codes for artificial hearts.

05/15/05

Revision to add clarification regarding artificial heart or mechanical devices.

08/15/05

Scheduled review; no change in coverage statement.

08/15/06

Scheduled review (consensus review); no change in coverage statement.

07/15/07

Scheduled review; revised Description section; reformatted guideline; updated references.

07/15/08

Scheduled review; no change to position statement. Add CMS language for clinical trials. Update references. Update Internet links.

01/01/09

Annual HCPCS coding update: update descriptor 0048T; delete 0049T.

07/15/09

Scheduled review; no change in position statement. Update references.

01/01/10

Annual HCPCS coding update: add CPT codes 93750, 33981, 33982, & 33983 and HCPCS code Q0506; remove code range Q0480 – Q0505 and add codes with full descriptors for all replacement parts and accessories.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Added codes Q0478, Q0479. Revised descriptor for code Q0499.

10/15/11

Unscheduled review. Revised description section, position statement, CPT coding, ICD10 coding and definitions. Deleted Medicare Exception and updated references.

01/01/13

Annual CPT/HCPCS coding update. Added 33990, 33991, 33992 and 33993. Revised descriptor for 93750. Deleted 0048T and 0050T. Corrected descriptors for Q0478 and Q0479.

04/01/13

2nd quarter HCPCS coding update. Added Q0507, Q0508 and Q0509. Deleted Q0505.

06/15/13

Unscheduled review. Revised description section, position statement and program exceptions section. Updated references and reformatted guideline.

07/01/14

Deleted codes 92970 , 92971, 93750, Q0478, Q0479, Q0480, Q0481, Q0482, Q0483, Q0484, Q0485, Q0486, Q0487, Q0488, Q0489, Q0490, Q0491, Q0492, Q0493, Q0494, Q0495, Q0496, Q0497, Q0498, Q0499, Q0500, Q0501, Q0502, Q0503, Q0504, Q0506, Q0507, Q0508 and Q0509.

11/01/15

Revision: ICD-9 Codes deleted.

03/15/16

Scheduled review. Revised description section and index terms. Maintained position statement. Updated references. Reformatted guideline.

01/01/17

Annual CPT/HCPCS update. Added 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T.

03/15/17

Scheduled review. Revised description section, coverage for rVAD, index terms, and program exceptions section. Updated references. Reformatted guideline.

Date Printed: June 23, 2017: 11:35 AM