Aetna · Clinical coverage policy

Aetna Cardiac Resynchronization Therapy (Biventricular Pacing) coverage criteria

Aetna covers FDA-approved biventricular pacemakers (cardiac resynchronization therapy, CRT) for congestive heart failure patients in sinus rhythm who are at least 40 days post-MI and on 3 months of optimal medical therapy with LVEF ≤ 35%, meeting either NYHA III-IV with QRS ≥ 150 msec OR NYHA II-IV with LBBB and QRS ≥ 130 msec; a combination CRT-defibrillator (CRT-D) is covered when those criteria are met plus a defined ventricular-arrhythmia risk factor. The key gates are NYHA class, LVEF threshold, QRS duration/morphology, optimized drug therapy, and post-MI timing. CRT/CRT-D for other indications (e.g., atrial fibrillation, NYHA I, anti-bradycardia pacing), and items such as wireless LV endocardial pacing, His bundle pacing for CRT, Galectin-3 testing, and implantable diaphragmatic stimulation are considered experimental/investigational, while CRT with an existing LVAD or for reversible/temporary heart failure is not medically necessary.

Policy CPB 0610 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0610

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0610 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Cardiac Resynchronization Therapy (Biventricular Pacing) (CPT 33208), and what gets it denied?

Path
Aetna covers FDA-approved biventricular pacemakers (cardiac resynchronization therapy, CRT) for congestive heart failure patients in sinus rhythm who are at least 40 days post-MI and on 3 months of optimal medical therapy with LVEF ≤ 35%, meeting either NYHA III-IV with QRS ≥ 150 msec OR NYHA II-IV with LBBB and QRS ≥ 130 msec; a combination CRT-defibrillator (CRT-D) is covered when those criteria are met plus a defined ventricular-arrhythmia risk factor. The key gates are NYHA class, LVEF threshold, QRS duration/morphology, optimized drug therapy, and post-MI timing. CRT/CRT-D for other indications (e.g., atrial fibrillation, NYHA I, anti-bradycardia pacing), and items such as wireless LV endocardial pacing, His bundle pacing for CRT, Galectin-3 testing, and implantable diaphragmatic stimulation are considered experimental/investigational, while CRT with an existing LVAD or for reversible/temporary heart failure is not medically necessary. Coverage criteria include: Aetna considers FDA-approved biventricular pacemakers (cardiac resynchronization therapy / CRT) medically necessary for congestive heart failure (CHF) patients in sinus rhythm who meet EITHER Criterion A OR Criterion B (below).; Criterion A (NYHA Class III or IV) — meet ALL of: NYHA functional class III or IV; AND left ventricular ejection fraction (LVEF) ≤ 35%; AND QRS duration ≥ 150 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-myocardial infarction (post-MI).; Criterion B (NYHA Class II-IV) — meet ALL of: NYHA functional class II, III, or IV; AND LVEF ≤ 35%; AND left bundle branch block (LBBB) with QRS duration ≥ 130 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-MI.; Combination resynchronization-defibrillator devices (CRT-D): medically necessary when the CRT medically-necessary criteria above (Criterion A or B) are met AND ANY ONE of the following is present: (1) at least one (≥1) episode of cardiac arrest due to ventricular tachyarrhythmia; OR (2) recurring, poorly tolerated sustained ventricular tachycardia; OR (3) prior MI with documented non-sustained ventricular tachycardia and inducible ventricular tachyarrhythmia; OR (4) prior MI with LVEF ≤ 30%.; Left bundle branch pacing: medically necessary when cardiac resynchronization therapy is indicated but left ventricular (LV) pacing cannot be accomplished.. Applies to 19 codes: 33208, 33213, 33214, 33224, 33225, 33249, 33230, 33231, 33240, 33262, 33263, 33264, C1779, C1785, C1882, C1898, C1899, C1900, G0448.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Experimental, investigational, or unproven: Biventricular pacemakers for all other indications not noted as medically necessary above (e.g., atrial fibrillation, mild heart failure / NYHA functional class I, and anti-bradycardia pacing).; Experimental, investigational, or unproven: Cardiac resynchronization therapy with wireless left ventricular endocardial pacing for the treatment of heart failure.; Experimental, investigational, or unproven: Combination resynchronization-defibrillator devices for all other indications (except those listed as medically necessary above).; Experimental, investigational, or unproven: Galectin-3 test for selecting individuals for cardiac resynchronization therapy and for all other indications (e.g., prediction of outcome in individuals with stable dilated cardiomyopathy, prognosis of aortic valve stenosis / heart failure, risk prediction of atrial fibrillation).; Experimental, investigational, or unproven: His bundle pacing for cardiac resynchronization therapy.; Experimental, investigational, or unproven: Implantable diaphragmatic stimulation (e.g., VisCardia's VisONE implantable system) for the treatment of heart failure.; Not medically necessary: Adjunctive cardiac resynchronization therapy in individuals with a left ventricular assist device currently in place.; Not medically necessary: Biventricular pacemakers (cardiac resynchronization therapy) or combination resynchronization-defibrillator devices for individuals whose heart failure or ventricular arrhythmias are reversible or temporary.; Contraindication (basis for non-coverage): Asynchronous pacing is contraindicated in the presence (or likelihood) of competitive paced and intrinsic rhythms.; Contraindication (basis for non-coverage): Unipolar pacing is contraindicated in individuals with an implanted defibrillator or cardioverter-defibrillator (ICD) because it may cause unwanted delivery or inhibition of defibrillator or ICD therapy. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0610 — Cardiac Resynchronization Therapy (Biventricular Pacing)

Coverage criteria

  • Aetna considers FDA-approved biventricular pacemakers (cardiac resynchronization therapy / CRT) medically necessary for congestive heart failure (CHF) patients in sinus rhythm who meet EITHER Criterion A OR Criterion B (below).
  • Criterion A (NYHA Class III or IV) — meet ALL of: NYHA functional class III or IV; AND left ventricular ejection fraction (LVEF) ≤ 35%; AND QRS duration ≥ 150 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-myocardial infarction (post-MI).
  • Criterion B (NYHA Class II-IV) — meet ALL of: NYHA functional class II, III, or IV; AND LVEF ≤ 35%; AND left bundle branch block (LBBB) with QRS duration ≥ 130 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-MI.
  • Combination resynchronization-defibrillator devices (CRT-D): medically necessary when the CRT medically-necessary criteria above (Criterion A or B) are met AND ANY ONE of the following is present: (1) at least one (≥1) episode of cardiac arrest due to ventricular tachyarrhythmia; OR (2) recurring, poorly tolerated sustained ventricular tachycardia; OR (3) prior MI with documented non-sustained ventricular tachycardia and inducible ventricular tachyarrhythmia; OR (4) prior MI with LVEF ≤ 30%.
  • Left bundle branch pacing: medically necessary when cardiac resynchronization therapy is indicated but left ventricular (LV) pacing cannot be accomplished.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Cardiac Resynchronization Therapy (Biventricular Pacing) (CPT 33208), and what gets it denied?
Aetna covers FDA-approved biventricular pacemakers (cardiac resynchronization therapy, CRT) for congestive heart failure patients in sinus rhythm who are at least 40 days post-MI and on 3 months of optimal medical therapy with LVEF ≤ 35%, meeting either NYHA III-IV with QRS ≥ 150 msec OR NYHA II-IV with LBBB and QRS ≥ 130 msec; a combination CRT-defibrillator (CRT-D) is covered when those criteria are met plus a defined ventricular-arrhythmia risk factor. The key gates are NYHA class, LVEF threshold, QRS duration/morphology, optimized drug therapy, and post-MI timing. CRT/CRT-D for other indications (e.g., atrial fibrillation, NYHA I, anti-bradycardia pacing), and items such as wireless LV endocardial pacing, His bundle pacing for CRT, Galectin-3 testing, and implantable diaphragmatic stimulation are considered experimental/investigational, while CRT with an existing LVAD or for reversible/temporary heart failure is not medically necessary. Coverage criteria include: Aetna considers FDA-approved biventricular pacemakers (cardiac resynchronization therapy / CRT) medically necessary for congestive heart failure (CHF) patients in sinus rhythm who meet EITHER Criterion A OR Criterion B (below).; Criterion A (NYHA Class III or IV) — meet ALL of: NYHA functional class III or IV; AND left ventricular ejection fraction (LVEF) ≤ 35%; AND QRS duration ≥ 150 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-myocardial infarction (post-MI).; Criterion B (NYHA Class II-IV) — meet ALL of: NYHA functional class II, III, or IV; AND LVEF ≤ 35%; AND left bundle branch block (LBBB) with QRS duration ≥ 130 msec; AND on an optimal/maximally-titrated pharmacologic regimen for 3 months (including ACE inhibitors, ARBs, beta-blockers, digoxin, and/or diuretics); AND ≥ 40 days post-MI.; Combination resynchronization-defibrillator devices (CRT-D): medically necessary when the CRT medically-necessary criteria above (Criterion A or B) are met AND ANY ONE of the following is present: (1) at least one (≥1) episode of cardiac arrest due to ventricular tachyarrhythmia; OR (2) recurring, poorly tolerated sustained ventricular tachycardia; OR (3) prior MI with documented non-sustained ventricular tachycardia and inducible ventricular tachyarrhythmia; OR (4) prior MI with LVEF ≤ 30%.; Left bundle branch pacing: medically necessary when cardiac resynchronization therapy is indicated but left ventricular (LV) pacing cannot be accomplished.. Applies to 19 codes: 33208, 33213, 33214, 33224, 33225, 33249, 33230, 33231, 33240, 33262, 33263, 33264, C1779, C1785, C1882, C1898, C1899, C1900, G0448. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Experimental, investigational, or unproven: Biventricular pacemakers for all other indications not noted as medically necessary above (e.g., atrial fibrillation, mild heart failure / NYHA functional class I, and anti-bradycardia pacing).; Experimental, investigational, or unproven: Cardiac resynchronization therapy with wireless left ventricular endocardial pacing for the treatment of heart failure.; Experimental, investigational, or unproven: Combination resynchronization-defibrillator devices for all other indications (except those listed as medically necessary above).; Experimental, investigational, or unproven: Galectin-3 test for selecting individuals for cardiac resynchronization therapy and for all other indications (e.g., prediction of outcome in individuals with stable dilated cardiomyopathy, prognosis of aortic valve stenosis / heart failure, risk prediction of atrial fibrillation).; Experimental, investigational, or unproven: His bundle pacing for cardiac resynchronization therapy.; Experimental, investigational, or unproven: Implantable diaphragmatic stimulation (e.g., VisCardia's VisONE implantable system) for the treatment of heart failure.; Not medically necessary: Adjunctive cardiac resynchronization therapy in individuals with a left ventricular assist device currently in place.; Not medically necessary: Biventricular pacemakers (cardiac resynchronization therapy) or combination resynchronization-defibrillator devices for individuals whose heart failure or ventricular arrhythmias are reversible or temporary.; Contraindication (basis for non-coverage): Asynchronous pacing is contraindicated in the presence (or likelihood) of competitive paced and intrinsic rhythms.; Contraindication (basis for non-coverage): Unipolar pacing is contraindicated in individuals with an implanted defibrillator or cardioverter-defibrillator (ICD) because it may cause unwanted delivery or inhibition of defibrillator or ICD therapy. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Cardiac Resynchronization Therapy (Biventricular Pacing)?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Cardiac Resynchronization Therapy (Biventricular Pacing)?
Policy exclusions and limitations: Experimental, investigational, or unproven: Biventricular pacemakers for all other indications not noted as medically necessary above (e.g., atrial fibrillation, mild heart failure / NYHA functional class I, and anti-bradycardia pacing).; Experimental, investigational, or unproven: Cardiac resynchronization therapy with wireless left ventricular endocardial pacing for the treatment of heart failure.; Experimental, investigational, or unproven: Combination resynchronization-defibrillator devices for all other indications (except those listed as medically necessary above).; Experimental, investigational, or unproven: Galectin-3 test for selecting individuals for cardiac resynchronization therapy and for all other indications (e.g., prediction of outcome in individuals with stable dilated cardiomyopathy, prognosis of aortic valve stenosis / heart failure, risk prediction of atrial fibrillation).; Experimental, investigational, or unproven: His bundle pacing for cardiac resynchronization therapy.; Experimental, investigational, or unproven: Implantable diaphragmatic stimulation (e.g., VisCardia's VisONE implantable system) for the treatment of heart failure.; Not medically necessary: Adjunctive cardiac resynchronization therapy in individuals with a left ventricular assist device currently in place.; Not medically necessary: Biventricular pacemakers (cardiac resynchronization therapy) or combination resynchronization-defibrillator devices for individuals whose heart failure or ventricular arrhythmias are reversible or temporary.; Contraindication (basis for non-coverage): Asynchronous pacing is contraindicated in the presence (or likelihood) of competitive paced and intrinsic rhythms.; Contraindication (basis for non-coverage): Unipolar pacing is contraindicated in individuals with an implanted defibrillator or cardioverter-defibrillator (ICD) because it may cause unwanted delivery or inhibition of defibrillator or ICD therapy. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0610 — Cardiac Resynchronization Therapy (Biventricular Pacing)

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0610 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.