TL;DR: Aetna, a CVS Health company, modified CPB 0610 governing cardiac resynchronization therapy (CRT) coverage policy, effective December 4, 2025. Billing teams managing CPT codes 33224, 33225, 33249, and related CRT device codes need to review updated medical necessity criteria before submitting claims.
This update to CPB 0610 Aetna system touches biventricular pacemakers, combination CRT-defibrillator devices, left bundle branch pacing, and several experimental designations. The policy covers a wide range of CPT and HCPCS codes — from 33208 through 33264 and C1779 through G0448 — along with clear exclusions for emerging technologies like wireless cardiac stimulation (CPT 0515T–0522T) and synchronized diaphragmatic stimulation systems. If your team handles cardiac device billing for heart failure patients, this policy directly affects your reimbursement.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Cardiac Resynchronization Therapy and Other Pacing/Defibrillator Treatments for Heart Failure |
| Policy Code | CPB 0610 |
| Change Type | Modified |
| Effective Date | December 4, 2025 |
| Impact Level | High |
| Specialties Affected | Electrophysiology, Cardiology, Cardiac Surgery, Cardiac Device Billing |
| Key Action | Audit your CRT claim documentation against updated LVEF, QRS, NYHA, and pharmacologic regimen criteria before submitting claims after December 4, 2025 |
Aetna Cardiac Resynchronization Therapy Coverage Criteria and Medical Necessity Requirements 2025
The Aetna cardiac resynchronization therapy coverage policy sets out two distinct pathways to meet medical necessity for CRT biventricular pacemakers. Both require the member to be in sinus rhythm with a left ventricular ejection fraction (LVEF) of 35% or less. Get these criteria right on your documentation or the claim denial risk is high.
Pathway A applies to NYHA Class III or IV heart failure. The member needs a QRS duration of 150 msec or greater, at least three months on a maximally titrated pharmacologic regimen (ACE inhibitor, ARB, beta blocker, digoxin, or diuretics — any of these, unless contraindicated), and must be at least 40 days post-myocardial infarction.
Pathway B is broader — it covers NYHA Class II through IV. Here, the specific requirement is left bundle branch block (LBBB) with a QRS duration of 130 msec or greater, the same three-month pharmacologic regimen requirement, and the same 40-day post-MI threshold.
The difference between these two pathways matters for your billing team. Pathway A demands a higher QRS threshold (150 msec vs. 130 msec) but doesn't require LBBB. Pathway B accepts a lower QRS threshold but requires documented LBBB. If your cardiologist's notes don't specify the conduction pattern, you can't confirm which pathway applies — and that ambiguity leads to claim denial.
For combination CRT-defibrillator devices — billed under CPT 33249, 33262, 33263, 33264, or HCPCS G0448 — the member must meet CRT criteria above and at least one additional criterion: a history of cardiac arrest from ventricular tachyarrhythmias, recurring sustained ventricular tachycardia, prior MI with documented non-sustained VT and inducible ventricular tachyarrhythmia, or prior MI with LVEF of 30% or less. Code ICD-10 Z86.74 (personal history of sudden cardiac arrest) alongside the appropriate ventricular tachycardia codes (I47.20, I47.21, I47.29) when those conditions apply.
Aetna also covers left bundle branch pacing as medically necessary — but only when CRT is indicated and left ventricular pacing can't be accomplished. This is a specific fallback indication. Document the failed LV pacing attempt explicitly in the clinical record before billing this approach.
This coverage policy does not mention specific prior authorization requirements in the criteria summary, but the complexity of these indications and the high cost of implantable cardiac devices makes prior auth standard practice in most Aetna plans. Verify prior auth requirements for each specific plan before scheduling procedures.
Aetna Cardiac Resynchronization Therapy Exclusions and Non-Covered Indications
Aetna is explicit about what doesn't qualify. Your team needs to know these exclusions cold, because submitting claims for these situations will result in denial.
Not medically necessary:
| # | Excluded Procedure |
|---|---|
| 1 | CRT as an adjunct in members who already have a left ventricular assist device (LVAD) in place |
| 2 | Biventricular pacemakers or CRT-defibrillators when the heart failure or ventricular arrhythmia is reversible or temporary |
| 3 | Asynchronous pacing when competitive paced and intrinsic rhythms are present or likely |
| 4 | Unipolar pacing in members with an existing ICD or cardioverter-defibrillator — it can cause unwanted therapy delivery or inhibition |
Experimental, investigational, or unproven:
| # | Excluded Procedure |
|---|---|
| 1 | Biventricular pacemakers for indications outside the defined criteria (the policy summary was truncated here, but expect this to cover off-label CHF indications) |
| 2 | Wireless cardiac stimulation (CPT 0515T through 0522T) — this is a flat exclusion |
| 3 | Synchronized diaphragmatic stimulation systems (CPT 0674T through 0685T) — also a flat exclusion |
| 4 | Galectin-3 testing (CPT 82777, CPT 83520) for heart failure prognosis — not covered |
| 5 | Aortic valve stenosis prognosis applications (ICD-10 I35.0) — not covered |
The wireless cardiac stimulation exclusion is worth flagging specifically. CPT codes 0515T through 0522T represent newer technologies for left ventricular pacing. Aetna's position is clear: these are not covered under this coverage policy. If your electrophysiology program has been trialing these approaches, make sure your billing guidelines reflect that Aetna will not reimburse them.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| CRT (biventricular pacemaker) — NYHA III/IV, LVEF ≤35%, QRS ≥150 msec, 3-month pharmacologic regimen, ≥40 days post-MI | Covered | CPT 33224, 33225, 33208, 33213, 33214; HCPCS C1785, C2619, C2620, C2621 | Sinus rhythm required; document all criteria |
| CRT (biventricular pacemaker) — NYHA II–IV, LVEF ≤35%, LBBB with QRS ≥130 msec, 3-month regimen, ≥40 days post-MI | Covered | CPT 33224, 33225, 33208, 33213, 33214; HCPCS C1785, C2619, C2620, C2621 | LBBB must be documented |
| Combination CRT-defibrillator — CRT criteria met + cardiac arrest, sustained VT, or LVEF ≤30% with prior MI | Covered | CPT 33230, 33231, 33240, 33249, 33262, 33263, 33264; HCPCS C1882, G0448 | High sudden cardiac death risk required |
| Left bundle branch pacing — CRT indicated, LV pacing not achievable | Covered | CPT 33224, 33225 | Document failure of LV pacing approach |
| CRT adjunctive to LVAD | Not Covered | All CRT CPT/HCPCS | Flat exclusion |
| CRT for reversible or temporary heart failure/arrhythmia | Not Covered | All CRT CPT/HCPCS | Must be persistent condition |
| Wireless cardiac stimulation for LV pacing | Not Covered / Experimental | CPT 0515T–0522T | Flat exclusion regardless of indication |
| Synchronized diaphragmatic stimulation | Not Covered / Experimental | CPT 0674T–0685T | Full code range excluded |
| Galectin-3 testing for HF prognosis | Not Covered | CPT 82777, CPT 83520 | Not covered under I50.1–I50.9 |
| Unipolar pacing with existing ICD | Not Covered | — | Safety contraindication cited |
Aetna Cardiac Resynchronization Therapy Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Audit your documentation templates before December 4, 2025. Every CRT claim needs explicit documentation of NYHA class, LVEF percentage, QRS duration, conduction pattern (LBBB vs. non-LBBB), pharmacologic regimen duration, and days post-MI. Missing any single element gives Aetna grounds for denial. |
| 2 | Update your charge capture to flag 0515T–0522T for Aetna patients. Wireless cardiac stimulation codes are not covered. If your electrophysiology team bills these for Aetna members, build a hard stop in your charge capture system now — before the effective date of December 4, 2025. |
| 3 | Confirm pathway documentation before billing CRT-defibrillator codes. For CPT 33249, 33262, 33263, 33264, and HCPCS G0448, you need both CRT criteria and at least one ICD-qualifying criterion documented. Pair the correct ICD-10 codes — I47.20–I47.29 for ventricular tachycardia, I46.2 for cardiac arrest, Z86.74 for cardiac arrest history — with your procedure codes. Don't leave it to the coder to infer. |
| 4 | Separate out Galectin-3 test orders for Aetna patients. CPT 82777 and 83520 are excluded under this policy when tied to heart failure diagnoses (I50.1–I50.9). If your cardiology team orders these tests for heart failure prognosis, notify them that Aetna cardiac resynchronization therapy billing guidelines explicitly exclude reimbursement. This isn't just a coverage gap — submitting these claims without disclosure creates compliance exposure. |
| 5 | Document LVAD status before any CRT claim. If a member has an active left ventricular assist device, CRT is not covered. Build a field in your pre-authorization workflow to capture LVAD status. Catching this upstream saves a denial cycle. |
| 6 | Verify reversibility documentation for borderline cases. Aetna excludes CRT for reversible or temporary arrhythmias and heart failure. Make sure your physician's notes address the chronic, persistent nature of the condition — not just the acute presentation. |
| 7 | If your practice is evaluating left bundle branch pacing as a CRT alternative, talk to your compliance officer before billing. Coverage is narrow — it requires documented CRT indication and documented inability to achieve LV pacing. The clinical and documentation burden here is higher than standard CRT. Get that workflow confirmed before claims go out. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Cardiac Resynchronization Therapy Under CPB 0610
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| 33208 | Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular |
| 33213 | Insertion of pacemaker pulse generator only; with existing dual leads |
| 33214 | Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system |
| 33224 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to existing pacemaker |
| 33225 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion or replacement of pacing cardioverter-defibrillator |
| 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 |
| 33240 | Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead |
| 33249 | Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous leads |
| 33262 | Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator |
| 33263 | Removal with replacement; with existing dual lead system |
| 33264 | Removal with replacement; with existing multiple lead system |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| C1779 | Lead, pacemaker, transvenous VDD single pass |
| C1785 | Pacemaker, dual chamber, rate-responsive (implantable) |
| C1882 | Cardioverter-defibrillator, other than single or dual chamber (implantable) |
| C1895 | Lead, cardioverter-defibrillator, endocardial dual coil (implantable) |
| C1896 | Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) |
| C1898 | Lead, pacemaker, other than transvenous VDD single pass |
| C1899 | Lead, left pacemaker/cardioverter-defibrillator combination (implantable) |
| C1900 | Lead, left ventricular coronary venous system |
| C2619 | Pacemaker, dual chamber, non rate-responsive (implantable) |
| C2620 | Pacemaker, single chamber, non rate-responsive (implantable) |
| C2621 | Pacemaker, other than single or dual chamber (implantable) |
| C7537 | Insertion of new or replacement of permanent pacemaker with atrial transvenous electrode(s), with intraoperative electrophysiologic evaluation and programming |
| C7538 | Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with intraoperative electrophysiologic evaluation and programming |
| C7539 | Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrodes, with intraoperative electrophysiologic evaluation and programming |
| C7540 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with intraoperative electrophysiologic evaluation and programming |
| G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous leads |
Not Covered / Experimental CPT Codes
| Code | Description | Reason |
|---|---|---|
| 0515T–0522T | Wireless cardiac stimulation system for left ventricular pacing | Not covered — experimental/investigational |
| 0674T | Laparoscopic insertion of new or replacement of permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0675T | Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0676T | Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system (additional lead) | Not covered for listed indications |
| 0677T | Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0678T | Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system (additional lead) | Not covered for listed indications |
| 0679T | Laparoscopic removal of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0680T | Insertion or replacement of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0681T | Relocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0682T | Removal of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0683T | Programming device evaluation (in-person) with iterative adjustment, synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0684T | Peri-procedural device evaluation (in-person) and programming, synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 0685T | Interrogation device evaluation (in-person) with analysis, review and report, synchronized diaphragmatic stimulation system | Not covered for listed indications |
| 82777 | Galectin-3 | Not covered for heart failure indications |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative | Other CPT — not covered for Galectin-3 heart failure prognosis |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| I20.0–I22.9, I24.0–I25.2 | Acute, subacute, and old myocardial infarction (prior MI with non-sustained VT or LVEF ≤30%) |
| I35.0 | Nonrheumatic aortic (valve) stenosis — not covered for prognosis |
| I42.0 | Dilated cardiomyopathy — not covered for Galectin-3 |
| I46.2 | Cardiac arrest due to underlying cardiac condition |
| I47.10–I47.19 | Supraventricular tachycardia (with at least one episode of cardiac arrest) |
| I47.20 | Ventricular tachycardia (with cardiac arrest or recurrent tachycardia) |
| I47.21 | Ventricular tachycardia |
| I47.29 | Ventricular tachycardia, unspecified |
| I48.0 | Atrial fibrillation |
| I50.1 | Left ventricular failure — CHF in sinus rhythm meeting criteria A or B |
| I50.2 | Systolic heart failure |
| I50.3 | Diastolic heart failure |
| I50.4 | Combined systolic and diastolic heart failure |
| I50.5 | Heart failure with reduced ejection fraction |
| I50.6 | Heart failure with mid-range ejection fraction |
| I50.7 | Heart failure with preserved ejection fraction |
| I50.8 | Other heart failure |
| I50.9 | Heart failure, unspecified |
| Z86.74 | Personal history of sudden cardiac arrest |
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