Aetna · Clinical coverage policy

Aetna Ventricular Assist Devices coverage criteria

Aetna CPB 0654 covers FDA-approved ventricular assist devices (VADs) for specific FDA-approved indications: as a bridge to transplant, as destination therapy (gated on NYHA Class IV end-stage failure, not a transplant candidate, failed optimal medical management, LVEF <25%, and peak O2 <=14 ml/kg/min unless waived), and for refractory electrical storm; it also covers percutaneous VADs for cardiogenic shock and high-risk PCI, pediatric VADs, short-term LVAD/RVAD/BiVAD for post-cardiotomy or refractory cardiogenic shock (up to 30 days), and the Impella RP for acute right heart failure (up to 14 days). All other VAD/pVAD indications, RVAD/pediatric use not meeting criteria, concomitant mitral valve surgery with LVAD, implantable aortic counter-pulsation systems (NuPulseCV iVAS, Symphony), and mesenchymal precursor cell adjunctive therapy are experimental/investigational. The bulletin is silent on precertification.

Policy CPB 0654 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0654

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0654 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 Ventricular Assist Devices (CPT 33975), and what gets it denied?

Path
Aetna CPB 0654 covers FDA-approved ventricular assist devices (VADs) for specific FDA-approved indications: as a bridge to transplant, as destination therapy (gated on NYHA Class IV end-stage failure, not a transplant candidate, failed optimal medical management, LVEF <25%, and peak O2 <=14 ml/kg/min unless waived), and for refractory electrical storm; it also covers percutaneous VADs for cardiogenic shock and high-risk PCI, pediatric VADs, short-term LVAD/RVAD/BiVAD for post-cardiotomy or refractory cardiogenic shock (up to 30 days), and the Impella RP for acute right heart failure (up to 14 days). All other VAD/pVAD indications, RVAD/pediatric use not meeting criteria, concomitant mitral valve surgery with LVAD, implantable aortic counter-pulsation systems (NuPulseCV iVAS, Symphony), and mesenchymal precursor cell adjunctive therapy are experimental/investigational. The bulletin is silent on precertification. Coverage criteria include: FDA-approved VAD is medically necessary for ANY of the following FDA-approved indications (bridge to transplant, destination therapy, or refractory electrical storm) as detailed in the items below.; Bridge to transplant: An FDA-approved VAD is medically necessary as a bridge to transplant for members who are awaiting heart transplantation AND the device has received FDA approval for a bridge-to-transplant indication (e.g., HeartMate 3 left ventricular assist system [LVAS]).; Destination therapy: An FDA-approved VAD is medically necessary when ALL of the following are met: (1) the device has received FDA approval for a destination therapy indication (e.g., HeartMate II LVAD and Aries HeartMate 3 [HM3]); AND (2) member has New York Heart Association (NYHA) Class IV end-stage ventricular heart failure and is not a candidate for heart transplant; AND (3) member has failed to respond to optimal medical management (including beta-blockers, and ACE inhibitors if tolerated) for at least 45 of the last 60 days, OR has been balloon pump dependent for 7 days, OR has been IV inotrope dependent for 14 days; AND (4) has a left ventricular ejection fraction (LVEF) less than 25%; AND (5) has demonstrated functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min (this peak-O2 criterion may be WAIVED in persons who are balloon pump or intravenous inotrope dependent or are otherwise unable to perform exercise stress testing).; Refractory electrical storm: An FDA-approved VAD is medically necessary for treatment of refractory electrical storm if member has tried and failed anti-arrhythmic drugs, deep sedation, AND catheter ablation (if rhythm appears ablatable) or a failed attempt at catheter ablation.; Percutaneous VADs (pVADs) (e.g., TandemHeart and Impella): FDA-approved pVADs are medically necessary for providing short-term circulatory support in cardiogenic shock.; Percutaneous VADs (pVADs) as an adjunct to percutaneous coronary intervention (PCI) are medically necessary in high-risk members meeting ANY ONE of: (a) members undergoing unprotected left main PCI with ejection fraction less than 35%; OR (b) members undergoing last-remaining-conduit PCI with ejection fraction less than 35%; OR (c) persons with three vessel disease and ejection fraction less than 30%.; Pediatric VADs: FDA-approved pediatric VADs are medically necessary when BOTH of the following are met: (1) child has documented end-stage left ventricular failure; AND (2) an age- and size-appropriate VAD will be used until a donor heart can be obtained. (Note: current FDA-approved pediatric VADs include the Berlin Heart EXCOR Pediatric Ventricular Assist Device for children aged 16 years or younger, and the HeartAssist 5 Pediatric Ventricular Assist Device for children aged 5 to 16 years.); Short-term LVADs, RVADs, or BiVADs (e.g., CentriMag): FDA-approved short-term LVADs, RVADs, or BiVADs are medically necessary for temporary circulatory support when BOTH of the following are met: (1) device(s) used for up to 30 days for members in post-cardiotomy cardiogenic shock, or refractory acute cardiogenic shock due to other causes, as a bridge to decision; AND (2) member is willing and able to be treated with heparin or an appropriate alternative anti-coagulant.; Impella RP System: medically necessary for providing circulatory assistance for up to 14 days in pediatric or adult persons with a body surface area >= 1.5 m2 who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery.. Applies to 15 codes: 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33992, 33993, 33995, 93750.
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: VADs are considered experimental, investigational, or unproven for all other indications (i.e., any indication beyond the medically necessary indications listed) because of insufficient evidence in the peer-reviewed literature.; pVADs are considered experimental, investigational, or unproven for all other indications, including during ablation of ventricular tachycardia, because of insufficient evidence in the peer-reviewed literature.; Pediatric VADs are considered experimental, investigational, or unproven when the stated criteria are not met.; RVADs are considered experimental, investigational, or unproven when the stated criteria are not met.; Concomitant mitral valve surgery with left ventricular assist device implantation for the treatment of mitral regurgitation is considered experimental, investigational, or unproven.; Implantable aortic counter-pulsation ventricular assist systems (e.g., the NuPulseCV iVAS and the Symphony Heart Assist System) are considered experimental, investigational, or unproven.; Use of mesenchymal precursor cells as adjunctive therapy in recipients of ventricular assist devices is considered experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0654 — Ventricular Assist Devices

Coverage criteria

  • FDA-approved VAD is medically necessary for ANY of the following FDA-approved indications (bridge to transplant, destination therapy, or refractory electrical storm) as detailed in the items below.
  • Bridge to transplant: An FDA-approved VAD is medically necessary as a bridge to transplant for members who are awaiting heart transplantation AND the device has received FDA approval for a bridge-to-transplant indication (e.g., HeartMate 3 left ventricular assist system [LVAS]).
  • Destination therapy: An FDA-approved VAD is medically necessary when ALL of the following are met: (1) the device has received FDA approval for a destination therapy indication (e.g., HeartMate II LVAD and Aries HeartMate 3 [HM3]); AND (2) member has New York Heart Association (NYHA) Class IV end-stage ventricular heart failure and is not a candidate for heart transplant; AND (3) member has failed to respond to optimal medical management (including beta-blockers, and ACE inhibitors if tolerated) for at least 45 of the last 60 days, OR has been balloon pump dependent for 7 days, OR has been IV inotrope dependent for 14 days; AND (4) has a left ventricular ejection fraction (LVEF) less than 25%; AND (5) has demonstrated functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min (this peak-O2 criterion may be WAIVED in persons who are balloon pump or intravenous inotrope dependent or are otherwise unable to perform exercise stress testing).
  • Refractory electrical storm: An FDA-approved VAD is medically necessary for treatment of refractory electrical storm if member has tried and failed anti-arrhythmic drugs, deep sedation, AND catheter ablation (if rhythm appears ablatable) or a failed attempt at catheter ablation.
  • Percutaneous VADs (pVADs) (e.g., TandemHeart and Impella): FDA-approved pVADs are medically necessary for providing short-term circulatory support in cardiogenic shock.
  • Percutaneous VADs (pVADs) as an adjunct to percutaneous coronary intervention (PCI) are medically necessary in high-risk members meeting ANY ONE of: (a) members undergoing unprotected left main PCI with ejection fraction less than 35%; OR (b) members undergoing last-remaining-conduit PCI with ejection fraction less than 35%; OR (c) persons with three vessel disease and ejection fraction less than 30%.
  • Pediatric VADs: FDA-approved pediatric VADs are medically necessary when BOTH of the following are met: (1) child has documented end-stage left ventricular failure; AND (2) an age- and size-appropriate VAD will be used until a donor heart can be obtained. (Note: current FDA-approved pediatric VADs include the Berlin Heart EXCOR Pediatric Ventricular Assist Device for children aged 16 years or younger, and the HeartAssist 5 Pediatric Ventricular Assist Device for children aged 5 to 16 years.)
  • Short-term LVADs, RVADs, or BiVADs (e.g., CentriMag): FDA-approved short-term LVADs, RVADs, or BiVADs are medically necessary for temporary circulatory support when BOTH of the following are met: (1) device(s) used for up to 30 days for members in post-cardiotomy cardiogenic shock, or refractory acute cardiogenic shock due to other causes, as a bridge to decision; AND (2) member is willing and able to be treated with heparin or an appropriate alternative anti-coagulant.
  • Impella RP System: medically necessary for providing circulatory assistance for up to 14 days in pediatric or adult persons with a body surface area >= 1.5 m2 who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery.

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 Ventricular Assist Devices (CPT 33975), and what gets it denied?
Aetna CPB 0654 covers FDA-approved ventricular assist devices (VADs) for specific FDA-approved indications: as a bridge to transplant, as destination therapy (gated on NYHA Class IV end-stage failure, not a transplant candidate, failed optimal medical management, LVEF <25%, and peak O2 <=14 ml/kg/min unless waived), and for refractory electrical storm; it also covers percutaneous VADs for cardiogenic shock and high-risk PCI, pediatric VADs, short-term LVAD/RVAD/BiVAD for post-cardiotomy or refractory cardiogenic shock (up to 30 days), and the Impella RP for acute right heart failure (up to 14 days). All other VAD/pVAD indications, RVAD/pediatric use not meeting criteria, concomitant mitral valve surgery with LVAD, implantable aortic counter-pulsation systems (NuPulseCV iVAS, Symphony), and mesenchymal precursor cell adjunctive therapy are experimental/investigational. The bulletin is silent on precertification. Coverage criteria include: FDA-approved VAD is medically necessary for ANY of the following FDA-approved indications (bridge to transplant, destination therapy, or refractory electrical storm) as detailed in the items below.; Bridge to transplant: An FDA-approved VAD is medically necessary as a bridge to transplant for members who are awaiting heart transplantation AND the device has received FDA approval for a bridge-to-transplant indication (e.g., HeartMate 3 left ventricular assist system [LVAS]).; Destination therapy: An FDA-approved VAD is medically necessary when ALL of the following are met: (1) the device has received FDA approval for a destination therapy indication (e.g., HeartMate II LVAD and Aries HeartMate 3 [HM3]); AND (2) member has New York Heart Association (NYHA) Class IV end-stage ventricular heart failure and is not a candidate for heart transplant; AND (3) member has failed to respond to optimal medical management (including beta-blockers, and ACE inhibitors if tolerated) for at least 45 of the last 60 days, OR has been balloon pump dependent for 7 days, OR has been IV inotrope dependent for 14 days; AND (4) has a left ventricular ejection fraction (LVEF) less than 25%; AND (5) has demonstrated functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min (this peak-O2 criterion may be WAIVED in persons who are balloon pump or intravenous inotrope dependent or are otherwise unable to perform exercise stress testing).; Refractory electrical storm: An FDA-approved VAD is medically necessary for treatment of refractory electrical storm if member has tried and failed anti-arrhythmic drugs, deep sedation, AND catheter ablation (if rhythm appears ablatable) or a failed attempt at catheter ablation.; Percutaneous VADs (pVADs) (e.g., TandemHeart and Impella): FDA-approved pVADs are medically necessary for providing short-term circulatory support in cardiogenic shock.; Percutaneous VADs (pVADs) as an adjunct to percutaneous coronary intervention (PCI) are medically necessary in high-risk members meeting ANY ONE of: (a) members undergoing unprotected left main PCI with ejection fraction less than 35%; OR (b) members undergoing last-remaining-conduit PCI with ejection fraction less than 35%; OR (c) persons with three vessel disease and ejection fraction less than 30%.; Pediatric VADs: FDA-approved pediatric VADs are medically necessary when BOTH of the following are met: (1) child has documented end-stage left ventricular failure; AND (2) an age- and size-appropriate VAD will be used until a donor heart can be obtained. (Note: current FDA-approved pediatric VADs include the Berlin Heart EXCOR Pediatric Ventricular Assist Device for children aged 16 years or younger, and the HeartAssist 5 Pediatric Ventricular Assist Device for children aged 5 to 16 years.); Short-term LVADs, RVADs, or BiVADs (e.g., CentriMag): FDA-approved short-term LVADs, RVADs, or BiVADs are medically necessary for temporary circulatory support when BOTH of the following are met: (1) device(s) used for up to 30 days for members in post-cardiotomy cardiogenic shock, or refractory acute cardiogenic shock due to other causes, as a bridge to decision; AND (2) member is willing and able to be treated with heparin or an appropriate alternative anti-coagulant.; Impella RP System: medically necessary for providing circulatory assistance for up to 14 days in pediatric or adult persons with a body surface area >= 1.5 m2 who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery.. Applies to 15 codes: 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33992, 33993, 33995, 93750. 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: VADs are considered experimental, investigational, or unproven for all other indications (i.e., any indication beyond the medically necessary indications listed) because of insufficient evidence in the peer-reviewed literature.; pVADs are considered experimental, investigational, or unproven for all other indications, including during ablation of ventricular tachycardia, because of insufficient evidence in the peer-reviewed literature.; Pediatric VADs are considered experimental, investigational, or unproven when the stated criteria are not met.; RVADs are considered experimental, investigational, or unproven when the stated criteria are not met.; Concomitant mitral valve surgery with left ventricular assist device implantation for the treatment of mitral regurgitation is considered experimental, investigational, or unproven.; Implantable aortic counter-pulsation ventricular assist systems (e.g., the NuPulseCV iVAS and the Symphony Heart Assist System) are considered experimental, investigational, or unproven.; Use of mesenchymal precursor cells as adjunctive therapy in recipients of ventricular assist devices is considered experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Ventricular Assist Devices?
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 Ventricular Assist Devices?
Policy exclusions and limitations: VADs are considered experimental, investigational, or unproven for all other indications (i.e., any indication beyond the medically necessary indications listed) because of insufficient evidence in the peer-reviewed literature.; pVADs are considered experimental, investigational, or unproven for all other indications, including during ablation of ventricular tachycardia, because of insufficient evidence in the peer-reviewed literature.; Pediatric VADs are considered experimental, investigational, or unproven when the stated criteria are not met.; RVADs are considered experimental, investigational, or unproven when the stated criteria are not met.; Concomitant mitral valve surgery with left ventricular assist device implantation for the treatment of mitral regurgitation is considered experimental, investigational, or unproven.; Implantable aortic counter-pulsation ventricular assist systems (e.g., the NuPulseCV iVAS and the Symphony Heart Assist System) are considered experimental, investigational, or unproven.; Use of mesenchymal precursor cells as adjunctive therapy in recipients of ventricular assist devices is considered experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0654 — Ventricular Assist Devices

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0654 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.