Summary: The Centers for Medicare & Medicaid Services modified its partial ventriculectomy coverage policy, effective May 15, 2026. Here's what billing teams need to do.
CMS partial ventriculectomy coverage policy changes don't come often — this procedure sits at the intersection of advanced cardiac surgery and strict Medicare coverage criteria. The Centers for Medicare & Medicaid Services has updated its position on partial ventriculectomy (also called the Batista procedure or left ventricular reduction surgery), and if your facility performs any volume of complex cardiac procedures, this modification is worth your full attention. This policy does not carry a numbered policy code in CMS's standard NCD or LCD framework — it stands as a standalone coverage determination. The policy document does not list specific CPT or HCPCS codes, so your team needs to identify the applicable procedure codes through your MAC's guidance before the May 15, 2026 effective date.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS |
| Policy | Partial Ventriculectomy |
| Policy Code | N/A |
| Change Type | Modified |
| Effective Date | May 15, 2026 |
| Impact Level | High |
| Specialties Affected | Cardiac surgery, cardiology, hospital inpatient billing, cardiovascular surgery centers |
| Key Action | Confirm CPT code assignment with your MAC and audit all pending partial ventriculectomy claims before May 15, 2026 |
CMS Partial Ventriculectomy Coverage Criteria and Medical Necessity Requirements 2026
Partial ventriculectomy — also called the Batista procedure — is a surgical technique that removes a wedge of the left ventricular wall to reduce chamber size and improve cardiac function in patients with dilated cardiomyopathy. CMS has historically treated this procedure with significant skepticism. The clinical evidence base has never been strong enough to earn it routine coverage status, and that tension shapes everything about how Medicare handles these claims.
The core issue with CMS partial ventriculectomy billing is medical necessity. CMS requires that any covered cardiac procedure meet a defined threshold of clinical evidence demonstrating improved patient outcomes. For partial ventriculectomy, that bar has been difficult to clear. The procedure peaked in interest during the late 1990s and early 2000s, but long-term outcome data consistently showed high mortality rates and limited durability compared to alternatives like cardiac transplantation and left ventricular assist devices.
What this policy modification signals is that CMS is formalizing or updating its coverage position — whether that means tightening the criteria, expanding access under specific conditions, or clarifying documentation requirements. Because the policy document does not include a detailed summary in the available data, your billing team should pull the full policy text directly from your Medicare Administrative Contractor before the effective date of May 15, 2026.
Prior authorization is not standard for surgical inpatient procedures under traditional Medicare, but medical necessity documentation is non-negotiable. CMS reviewers will scrutinize any partial ventriculectomy claim closely. Your documentation must show why less invasive or better-established alternatives were considered and ruled out.
CMS Partial Ventriculectomy Exclusions and Non-Covered Indications
CMS has historically treated partial ventriculectomy as experimental or investigational for most patient populations. That classification has real consequences — claims submitted without airtight medical necessity documentation face immediate denial risk.
The procedure is generally not covered for patients who are candidates for cardiac transplantation or left ventricular assist device (LVAD) implantation, since those alternatives carry stronger evidence. CMS coverage policy has also excluded partial ventriculectomy performed as a primary treatment for heart failure without documented failure of guideline-directed medical therapy.
Any claim that lacks documentation of patient-specific clinical rationale — including why the patient is not a transplant or LVAD candidate — is a claim denial waiting to happen. The burden of proof sits entirely with the billing and clinical teams, not with CMS.
Coverage Indications at a Glance
Because the policy document does not provide a detailed summary with enumerated indications, the table below reflects CMS's established clinical framework for this procedure, which this modification updates. Pull the full policy text from your MAC to confirm current coverage status for each indication before billing.
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Partial ventriculectomy for dilated cardiomyopathy, transplant-ineligible patients | Coverage status subject to policy modification — confirm with MAC | Not listed in policy data | Medical necessity documentation required; prior clinical workup must be documented |
| Partial ventriculectomy for patients who are transplant or LVAD candidates | Historically not covered | Not listed in policy data | Established alternatives exist; claim denial risk is high without extraordinary clinical justification |
| Partial ventriculectomy in clinical trial / research setting | May be covered under Medicare clinical trial policy | Not listed in policy data | Must meet Medicare Clinical Trial Policy requirements; separate coverage determination may apply |
| Partial ventriculectomy as experimental or investigational | Not covered | Not listed in policy data | CMS has historically classified this procedure as investigational for most indications |
CMS Partial Ventriculectomy Billing Guidelines and Action Items 2026
This is not a policy change you can sit on. The effective date is May 15, 2026, and any claims submitted on or after that date must align with the updated coverage policy — whatever the final version says.
| # | Action Item |
|---|---|
| 1 | Pull the full policy text from your MAC now. The policy data available here does not include a detailed summary. Go directly to your Medicare Administrative Contractor's website or contact their provider outreach line to get the full modified policy document before May 15, 2026. |
| 2 | Identify your applicable CPT codes before the effective date. The policy does not list specific codes. Work with your coding team and, if needed, your MAC to confirm which CPT codes map to partial ventriculectomy procedures in your charge master. Don't wait until after a denial to have this conversation. |
| 3 | Audit any pending or recently submitted partial ventriculectomy claims. If you have claims in process right now, check whether they'll fall under the old or new coverage policy. Claims with a date of service on or after May 15, 2026 are subject to the modified rules. |
| 4 | Review your medical necessity documentation templates. Physicians need to clearly document the patient's diagnosis, prior treatment history, why transplant and LVAD were considered and excluded, and the specific clinical rationale for partial ventriculectomy. Generic operative notes will not survive a CMS audit. |
| 5 | Check whether your facility has any active clinical trial patients. Medicare's Clinical Trial Policy may provide a coverage pathway for patients enrolled in an approved trial. This is a separate reimbursement track with its own documentation requirements, but it's worth flagging if your institution participates in cardiac surgery research. |
| 6 | Loop in your compliance officer before the effective date. This policy sits in high-risk territory — low procedure volume, high claim value, and a historical pattern of CMS skepticism about medical necessity. If you're uncertain how this modification applies to your patient population, get your compliance officer and billing consultant involved before May 15, 2026. |
The real issue here is that cardiac surgery billing teams often treat CMS policy changes on rare procedures as low priority. That's the wrong call. A single denied partial ventriculectomy claim can represent $40,000 to $80,000 in lost reimbursement. One case, denied on coverage grounds, will cost more than the time it takes to read the full policy today.
| 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 Partial Ventriculectomy Under This Policy
Code Data Availability
The CMS partial ventriculectomy policy, as provided in the available policy data, does not list specific CPT, HCPCS Level II, or ICD-10-CM codes. This is not unusual for CMS coverage determinations on low-volume surgical procedures — the code assignment often relies on general CPT surgical section codes rather than a procedure-specific HCPCS code.
Do not use any codes from this article as authoritative for this policy. Your coding team must identify the correct procedure codes independently.
How to Find the Correct Codes
Contact your Medicare Administrative Contractor directly. Ask specifically which CPT codes they expect on claims for partial ventriculectomy (left ventricular reduction surgery / Batista procedure). MACs have provider outreach lines specifically for this kind of coding question, and getting written guidance from your MAC protects you in an audit.
You can also check the CMS website at cms.gov and the full policy source at the PayerPolicy link for this determination. If a local coverage determination (LCD) exists in your MAC's jurisdiction that addresses cardiac surgical procedures, it may contain the relevant code list.
General Guidance (Not a Substitute for MAC Confirmation)
Partial ventriculectomy is a complex cardiac surgical procedure typically billed under hospital inpatient DRG groupings on the facility side. On the physician side, it falls within the cardiac surgery section of CPT. The specific code used depends on documentation of the exact surgical approach and any concurrent procedures performed. Your coding team should not assume a single-code solution — complex cardiac cases routinely require multiple CPT codes for the primary procedure and any add-on work performed.
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