1. No category

Regence
Medicare Advantage Policy Manual
TOPIC: Ventricular Assist Devices and Total Artificial Hearts
Section: Medicare Manual – Surgery
Approval Date: March 2015
Policy No: M-SUR52
Published Date: 05/01/2015
IMPORTANT REMINDER: The health plan’s Medicare Advantage Medical Policies are
developed to provide guidance for members and providers regarding coverage in accordance
with the member Evidence of Coverage (EOC) booklet. Benefit determinations are based in all
cases on any applicable EOC language and any applicable CMS policy. To the extent there
may be any conflict, applicable EOC language or applicable CMS policy take precedence over
the health plan’s Medicare Advantage Medical Policy.
MEDICARE MEDICAL POLICY CRITERIA
CMS Coverage Manuals
None
National Coverage
Determinations (NCD)
For artificial hearts:
 Artificial Hearts and Related Devices (20.9)
For ventricular assist devices (VADs):
 Ventricular Assist Devices (20.9.1)
NCD 20.9.1 was implemented 09/30/2014. For Medicareapproved VAD Destination Therapy Facilities, see CMS
Website.
Noridian Healthcare Solutions
(Noridian) Local Coverage
Determinations (LCD) and
Articles (LCA)
For percutaneous endovascular cardiac assist
devices:
 Percutaneous Endovascular Cardiac Assist
Procedures and Devices (A52906)
• Idaho
• Oregon
• Utah
1 - M-SUR52
•
Washington
**Scroll to the “All Versions” section at the bottom of the
LCD to access prior versions.
REFERENCES
None
CROSS REFERENCES
Surgical Ventricular Restoration, Surgery, Policy No. M-149
Heart Transplants, Transplant, Policy No. M-02
Heart/Lung Transplants, Transplant, Policy No. M-03
CODES NUMBER DESCRIPTION
Note: There is no specific code for reporting prolonged extracorporeal percutaneous
transseptal ventricular assist device; the appropriate code for reporting this procedure is
33999.
CPT
33975
Insertion of ventricular assist device; extracorporeal, single ventricle
33976
Insertion of ventricular assist device; extracorporeal, biventricular
33977
Removal of ventricular assist device; extracorporeal, single ventricle
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 ventricular
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
2 - M-SUR52
CODES NUMBER DESCRIPTION
radiological supervision and interpretation; both arterial and venous
access, with transseptal puncture
HCPCS
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
Q0478Q0509
Ventricular assist device accessories, code range
3 - M-SUR52