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. If your team has ever billed — or attempted to bill — for partial ventriculectomy, ventricular reduction, or heart volume reduction surgery, this policy confirms a hard denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Medicare) |
| Policy | Partial Ventriculectomy |
| Policy Code | NCD 122 |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | Medium — high denial risk for cardiac surgery practices billing this procedure |
| Specialties Affected | Cardiac surgery, cardiothoracic surgery, heart failure programs |
| Key Action | Flag partial ventriculectomy and all synonymous procedure names in your charge capture as non-covered under Medicare before March 7, 2026 |
CMS Partial Ventriculectomy Coverage Criteria and Medical Necessity Requirements 2026
The CMS partial ventriculectomy coverage policy is straightforward: Medicare does not cover this procedure. Full stop.
NCD 122 in the Medicare system classifies partial ventriculectomy as not reasonable and necessary under §1862(a)(1) of the Social Security Act. That statutory standard is the same bar CMS uses across hundreds of coverage decisions — and failing it means no reimbursement, regardless of individual patient circumstance.
The basis for the non-coverage decision comes down to two factors. The mortality rate for this procedure is high. And there are no published scientific articles or clinical studies supporting it. Those two conditions together make a medical necessity argument essentially impossible to sustain on appeal.
Whether you're asking whether partial ventriculectomy is covered under Medicare, the answer NCD 122 gives you is unambiguous. It is not. Prior authorization won't fix that. A letter of medical necessity won't fix that. The coverage policy forecloses the procedure categorically.
What Is Partial Ventriculectomy — And Why Medicare Won't Pay for It
Partial ventriculectomy goes by several names: ventricular reduction, ventricular remodeling, and heart volume reduction surgery. All of these refer to the same procedure. Your charge capture and your CDM should flag every one of those synonyms.
The procedure was developed by a Brazilian surgeon and has seen only limited use in the United States. It targets patients with enlarged hearts caused by end-stage congestive heart failure. The surgical approach involves excising a portion of the left ventricular wall, then repairing the defect — the theory being that a smaller left ventricle pumps more efficiently.
That theory hasn't been validated by published clinical research. CMS reviewed the evidence and found none. That absence of evidence is what drives the non-coverage determination under NCD 122.
This matters for billing teams at academic medical centers and large cardiac surgery programs in particular. These are the settings most likely to encounter a patient who traveled specifically to receive this procedure, or a surgeon who trained under a program that performs it. The CMS coverage policy does not carve out exceptions for academic research settings or investigational use under standard Medicare billing.
If your program is treating patients with experimental cardiac procedures, talk to your compliance officer before the March 7, 2026 effective date about how NCD 122 applies to your specific case mix.
CMS Partial Ventriculectomy Exclusions and Non-Covered Indications
NCD 122 is an exclusion policy. The entire scope of the determination is a non-coverage finding. There are no covered subsets of this procedure under Medicare.
The following clinical presentations are specifically addressed in NCD 122 — all are non-covered:
| # | Excluded Procedure |
|---|---|
| 1 | Partial ventriculectomy for end-stage congestive heart failure with cardiomegaly |
| 2 | Ventricular reduction surgery regardless of surgical approach |
| 3 | Heart volume reduction surgery performed to improve left ventricular efficiency |
| 4 | Ventricular remodeling procedures aligned with this surgical method |
The procedure's investigational status is not a billing technicality. It reflects a CMS determination that the evidence base simply does not exist to support coverage. That's a different situation from a procedure that's covered with restrictions — this one has no covered pathway at all under standard Medicare fee-for-service.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Partial ventriculectomy for end-stage CHF with enlarged heart | Not Covered | No specific codes listed in NCD 122 | Non-covered under §1862(a)(1); no exceptions |
| Ventricular reduction surgery | Not Covered | No specific codes listed in NCD 122 | Synonymous with partial ventriculectomy |
| Ventricular remodeling surgery | Not Covered | No specific codes listed in NCD 122 | Synonymous with partial ventriculectomy |
| Heart volume reduction surgery | Not Covered | No specific codes listed in NCD 122 | Synonymous with partial ventriculectomy |
CMS Partial Ventriculectomy Billing Guidelines and Action Items 2026
The modified NCD 122 is effective March 7, 2026. Here's what your billing team needs to do before then.
| # | Action Item |
|---|---|
| 1 | Audit your CDM for all synonymous procedure names. Search your charge description master for "partial ventriculectomy," "ventricular reduction," "ventricular remodeling," and "heart volume reduction surgery." Any of these terms attached to a billable charge under Medicare needs a hard stop or a non-covered flag before the effective date. |
| 2 | Review your ABN workflow for this procedure. If a patient requests this surgery and your facility proceeds with full disclosure of non-coverage, an Advance Beneficiary Notice of Noncoverage (ABN) must be in place before the service is rendered. Without a valid ABN, your facility absorbs the cost entirely. With one, the patient assumes financial responsibility. This is not optional. |
| 3 | Brief your cardiac surgery coding team on the non-coverage status. Partial ventriculectomy billing errors aren't just claim denial risks — they're compliance exposure. A coder who doesn't know this procedure is categorically excluded may code it as a covered cardiac surgery using a neighboring CPT code. That creates a false claim risk, not just a denial. |
| 4 | Check your MAC's local coverage landscape for any related LCDs. NCD 122 is a national coverage determination — it sets the floor for all Medicare Administrative Contractors. Your MAC cannot create a local coverage determination (LCD) that overrides a national non-coverage decision. But if your cardiac program bills related procedures, check whether your MAC has issued guidance on adjacent heart failure surgical interventions. |
| 5 | Flag this at your next revenue cycle review if you're affiliated with a heart failure program. Programs that treat advanced heart failure patients sometimes encounter requests for procedures that are outside standard Medicare coverage. NCD 122 is a clear example. Make sure your clinical and financial counseling teams know this procedure generates no reimbursement under Medicare — before the patient is scheduled, not after. |
| 6 | Do not attempt to use a related CPT code as a workaround. NCD 122 does not list specific CPT codes because the procedure itself has no standard code — it's that rare and that new. Using a neighboring cardiac surgery code to capture payment for a partial ventriculectomy is upcoding. Your compliance officer needs to be part of any conversation about how to document and bill cases where a surgeon performs elements of this procedure alongside covered services. |
| 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 NCD 122
NCD 122 does not list specific CPT, HCPCS, or ICD-10 codes. This is notable — and it's not an oversight.
The procedure is rare enough in the United States that it does not have a dedicated CPT code. That creates its own billing risk. When a procedure lacks a specific code, billing teams sometimes reach for the closest anatomical or surgical match. Under a non-covered NCD, that approach creates false claim exposure.
Why the Absence of Codes Matters for Partial Ventriculectomy Billing
When CMS issues a non-coverage determination without attaching specific codes, the non-coverage applies to the procedure — not to a code. That's an important distinction. It means the denial follows the clinical intent of the service, not just the code submitted.
If a surgeon performs a partial ventriculectomy and a coder submits a claim using a general cardiac surgery CPT code, the claim may process initially. But if that claim is audited and the documentation reveals the actual procedure performed was a non-covered partial ventriculectomy, your practice faces recoupment — plus potential fraud and abuse exposure.
Document the procedure accurately. Code it as accurately as the current CPT system allows. And if there is genuine ambiguity about how to code an element of the procedure, get a formal opinion from your billing consultant or compliance officer before the effective date of March 7, 2026.
A Note on ICD-10 Diagnosis Codes
End-stage congestive heart failure and cardiomegaly have ICD-10-CM codes. The presence of those diagnosis codes on a claim does not create coverage eligibility for partial ventriculectomy. A valid diagnosis does not override a national non-coverage determination. Don't let your team assume that a well-documented heart failure diagnosis unlocks this procedure for Medicare reimbursement. It doesn't.
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