Partial Ventriculectomy — NCD 122 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 122 governing partial ventriculectomy coverage, effective March 7, 2026. Medicare does not cover this procedure — and billing teams need to know exactly why before submitting any claim.

The CMS partial ventriculectomy coverage policy under NCD 122 is a non-coverage determination. The Centers for Medicare & Medicaid Services denies Medicare reimbursement for partial ventriculectomy — also called ventricular reduction, ventricular remodeling, or heart volume reduction surgery — based on a lack of published clinical evidence and an unacceptably high mortality rate. This policy lists no specific CPT or HCPCS codes, which creates its own set of billing complications.

Quick-Reference Table

CMS Partial Ventriculectomy Coverage Criteria and Medical Necessity Requirements 2026

CMS has one answer for partial ventriculectomy: not covered. Under NCD 122 in the Medicare National Coverage Determinations system, this procedure fails the medical necessity threshold set by §1862(a)(1) of the Social Security Act. That statute requires a service to be "reasonable and necessary" for Medicare to pay for it. Partial ventriculectomy doesn't meet that bar.

The reason is straightforward. CMS points to two specific problems. First, the mortality rate for this procedure is high. Second, there are no published scientific articles or clinical studies supporting its use. Without evidence, CMS cannot establish medical necessity — and without medical necessity, there is no coverage.

This is not a coverage policy with criteria you can meet through better documentation. There are no qualifying diagnoses, no patient populations where Medicare will pay, and no prior authorization pathway that unlocks reimbursement. The procedure is simply excluded.

If your cardiovascular surgery or cardiology team is performing partial ventriculectomy — or any of its clinical synonyms — on Medicare patients, you need to communicate this non-coverage determination before any claim is generated. The financial exposure is real, and so is the compliance risk.

CMS Partial Ventriculectomy Exclusions and Non-Covered Indications

The entire procedure is the exclusion. CMS treats partial ventriculectomy as not reasonable and necessary, which places it outside Medicare coverage entirely — not just in specific clinical scenarios, but across the board.

The procedure goes by several names in clinical and surgical settings. CMS's NCD 122 covers all of them under the same non-coverage ruling:

If a claim is submitted under any of those descriptions — regardless of what code is attached — Medicare will deny it. The clinical rationale your surgeon uses in the operative note doesn't change the outcome. CMS has made a national coverage determination, which means no Medicare Administrative Contractor has the authority to approve it locally.

This is an important distinction from a local coverage determination (LCD). An LCD can vary by region. A national coverage determination applies everywhere Medicare is the payer. There is no MAC in the country that can override NCD 122.

The clinical context matters here because it shapes how denials get mishandled. Partial ventriculectomy is performed on patients with end-stage congestive heart failure whose hearts have become enlarged. The surgeon excises a portion of the left ventricular wall to reduce the heart's size and improve pumping efficiency. These are often very sick patients, and the surgical team may believe the procedure is medically justified. That clinical judgment is separate from the coverage policy. CMS's position is that the evidence base doesn't exist to support Medicare payment — regardless of individual patient circumstances.

Coverage Indications at a Glance

CMS Partial Ventriculectomy Billing Guidelines and Action Items 2026

The effective date of March 7, 2026 means this modified policy is live now. Here is what your billing team, charge capture team, and compliance officer need to do.

If your facility treats a significant volume of end-stage heart failure patients, or if your cardiovascular surgery program has considered adding this procedure, loop in your compliance officer and legal counsel now — before March 7, 2026 activity creates claim exposure.

CPT, HCPCS, and ICD-10 Codes for Partial Ventriculectomy Under NCD 122

No Codes Specified in Policy Data

NCD 122 does not list specific CPT, HCPCS Level II, or ICD-10 codes. This is worth calling out because it creates a real gap in your billing edits.

The absence of codes is not unusual for older NCDs that predate the current billing code infrastructure. But it means your team can't simply load a code list into your claim scrubber and call it done. You need to identify the procedure codes your surgeons and facility use for partial ventriculectomy and its synonyms, then build your Medicare denial prevention edits around those specific codes.

Work with your cardiovascular surgery coding team and your chargemaster manager to identify those codes. Common starting points include surgical CPT codes for ventricular procedures, but this requires a code review by a qualified cardiac surgery coder — not a guess. Once you have the correct codes, add them to your Medicare non-covered procedure edits.

This is one of those situations where the billing guidelines require more internal work than a policy with a clean code list. Do the work now. A missed edit on a cardiac surgery claim is a high-dollar denial.