Advanced Bionics Reimbursement Guide - Boston Scientific



SAMPLE PRIOR AUTHORIZATION LETTER

Cardiac Implant Devices

______________________________________________________________________________

PLEASE NOTE: This letter is intended as an example for your consideration and may not include all the information necessary to support your prior authorization request. The requesting facility is entirely responsible for ensuring the accuracy, adequacy, and supportability of all the information provided. As a reminder, Medicare does not preauthorize medical procedures. It is recommended that you contact your patient’s insurance company to obtain specific inclusion/exclusion criteria.

[Date]

Attention: Surgery Preauthorization Department

[Insurance Company address]

Re: Patient Name: ____________________

Policy Holder Name: _______________

Patient ID #: _______________________

Policy, Group, or Claim # ____________

Dear Madam/Sir:

This letter is to request approval for the surgery, hospitalization, and post-surgical care associated with the planned implantation of a [select one] Cardiac Resynchronization Therapy defibrillator (CRT-D); Implantable Cardioverter-Defibrillator or Pacemaker for (patient name). This patient is schedule for surgery on [insert date].

CRT-D Therapy

Boston Scientific Cardiac Resynchronization Therapy Defibrillators (CRT-Ds)

are indicated for patients with heart failure who receive stable optimal pharmacologic

therapy (OPT) for heart failure and who meet any one of the following classifications:

• Moderate to severe heart failure (NYHA Class III-IV) with EF ≤ 35% and QRS

duration ≥ 120 ms

• Left bundle branch block (LBBB) with QRS duration ≥ 130 ms, EF ≤ 30%, and mild

(NYHA Class II) ischemic or nonischemic heart failure or asymptomatic (NYHA Class I) ischemic heart failure

ICD Therapy

Boston Scientific ICDs are intended to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias.

CRT-P Therapy

Boston Scientific cardiac resynchronization pacemakers (CRT-Ps) are indicated for patients with moderate to severe heart failure (NYHA Class III/IV) including left ventricular dysfunction (EF ≤ 35%) and QRS duration ≥ 120 ms and remain symptomatic despite stable optimal pharmacological therapy (OPT) for heart failure.

Atrial tracking modes are also indicated for patients who may benefit from maintenance

of AV synchrony. Adaptive-rate pacing is indicated for patients exhibiting chronotropic incompetence and who would benefit from increased pacing rates concurrent with increases in physical activity.

Pacemaker Therapy

Boston Scientific pacemakers are indicated for treatment of the following conditions:

• Symptomatic paroxysmal or permanent second- or third-degree AV block

• Symptomatic bilateral bundle branch block

• Symptomatic paroxysmal or transient sinus node dysfunction with or without

associated AV conduction disorders (i.e., sinus bradycardia, sinus arrest, sinoatrial

[SA] block

• Bradycardia-tachycardia syndrome, to prevent symptomatic bradycardia or some

forms of symptomatic tachyarrhythmias

• Neurovascular (vaso-vagal) syndromes or hypersensitive carotid sinus syndromes

Adaptive-rate pacing is indicated for patients exhibiting chronotropic incompetence and

who may benefit from increased pacing rates concurrent with increases in minute

ventilation and/or level of physical activity.

Dual-chamber and atrial tracking modes are also indicated for patients who may benefit from maintenance of AV synchrony.

Dual chamber modes are specifically indicated for treatment of the following:

• Conduction disorders that require restoration of AV synchrony, including varying

degrees of AV block

• VVI intolerance (i.e., pacemaker syndrome) in the presence of persistent sinus

rhythm

• Low cardiac output or congestive heart failure secondary to bradycardia

I am requesting approval to implant a Boston Scientific [insert name of device] in order to provide continued clinical benefit to my patient. The [insert name of device] is FDA approved for use in this patient.

This implant/replacement procedure is consistent with the current Medicare National Coverage Determination for ICDs and current published clinical guidelines [Select from the links below and include any applicable guidelines or specific clinical indications for your patient].

Click on the link below to access the CMS NCD for Implantable Automatic Defibrillators:



Click on the link below to access the CMS NCD for Pacemakers:



Click on the link below to access the HRS/ACCF Consensus Statement on Pacemaker Device and Mode Selection-June 2012:



Click on the link below to access the ACC/AHA/HRS 2008 Guidelines for Devices Based Therapy:



Click on the link below to access the HFSA CRT Guideline Update for CRT therapy:



I plan to use the following codes to bill for professional and facility services [Note: The sample list of codes below does not represent a complete list of all CPT® codes that may be used. Please refer to the most current version of the AM’s CPT code book for additional code(s) selection. Select the appropriate codes from the examples below that best describe the completed procedure(s). It may be helpful to delete any procedure codes that do not apply to a particular situation.]

|CRT-D / ICD CPT® Procedure Codes |

| 33240 |Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead |

| 33230 |Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads |

| 33231 |Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads |

| 33241 |Removal of pacing cardioverter-defibrillator pulse generator only |

| 33249 |Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single |

| |or dual chamber |

| 33262 |Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing |

| |cardioverter-defibrillator pulse generator; single lead system |

| 33263 |Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing |

| |cardioverter-defibrillator pulse generator; dual lead system |

| 33264 |Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing |

| |cardioverter-defibrillator pulse generator; multiple lead system |

| 33233 |Revision of skin pocket for cardioverter-defibrillator |

|ICD Defibrillator Lead CPT Procedure Codes |

| 33215 | Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial |

| |or right ventricular) electrode |

| 33216 |Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator |

| 33217 |Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator |

| 33218 |Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator |

| 33220 |Repair of 2 transvenous electrodes, permanent pacemaker or pacing cardioverter-defibrillator |

| 33224 |Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously |

| |placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal |

| |insertion, and/or replacement of existing generator) |

| 33225 |Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing|

| |cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket |

| |revision) (List separately in addition to code for primary procedure) |

| 33226 |Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, |

| |insertion and/or replacement of existing generator) |

| 33243 |Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoracotomy |

| 33244 |Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction |

|CRT-P / Pacemaker CPT Procedure Codes |

| 33206 |Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial |

| 33207 |Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular |

| 33208 |Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular |

| 33212 |Insertion of pacemaker pulse generator only; with existing single lead |

| 33213 |Insertion of pacemaker pulse generator only; with existing dual lead |

| 33221 |Insertion of pacemaker pulse generator only; with existing multiple lead |

| 33214 |Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes |

| |removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new |

| |pulse generator) |

| 33222 |Revision or relocation of skin pocket for pacemaker |

| 33233 |Removal of permanent pacemaker pulse generator only |

| 33227 |Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system |

| 33228 |Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system |

| 33229 |Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead |

| |system |

|Pacemaker Lead Procedure CPT Codes |

| 33215 | Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial |

| |or right ventricular) electrode |

| 33216 |Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator |

| 33217 |Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator |

| 33218 |Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator |

| 33220 |Repair of 2 transvenous electrodes, permanent pacemaker or pacing cardioverter-defibrillator |

| 33224 |Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously |

| |placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal |

| |insertion, and/or replacement of existing generator) |

| 33225 |Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing|

| |cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket |

| |revision) (List separately in addition to code for primary procedure) |

| 33226 |Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, |

| |insertion and/or replacement of existing generator) |

| 33234 |Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular |

| 33235 |Removal of transvenous pacemaker electrode(s); dual lead system |

|EP Evaluation of CRT-D / ICD System |

| 93641-26 |Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including |

| |defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia |

| |termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing |

| |cardioverter-defibrillator pulse generator |

|® CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.|

|Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related |

|components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or |

|indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. |

__(Patient name)__ is medically appropriate for this procedure, and we request that approval be granted for the surgery and all related services as soon as possible. Please fax your approval to my office at the following number (fax #)_ _ or contact me with additional questions that I may clarify. I can be reached at (tele # .

Sincerely,

[Physician Name]

[Practice Name]

[Phone Number]

The following medical record documentation is provided to support the medical necessity of performing this service.

Enclosures

• History and physical

• MD order and progress notes

• Pertinent test reports with written interpretation

• Office/progress notes

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