What documentation does Anthem require for CPT 33249?

Echocardiogram with LVEF within 90 days; EKG or rhythm monitoring documenting arrhythmia (if secondary prevention); NYHA functional class assessment; Current medication list with doses confirming GDMT; Documentation of primary vs. secondary prevention indication

How much does Medicare pay for CPT 33249 in 2026?

In 2026, the national Medicare allowable for CPT 33249 is $797.95 in an office setting and $797.95 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 33249?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 33249

Cardiac device procedures including insertion of left ventricular pacing electrode and insertion/replacement of permanent implantable defibrillator system · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for ICD implantation via Carelon. Primary prevention: LVEF <=35% NYHA II-III on GDMT >=90 days. Secondary prevention: documented sustained VT/VF or cardiac arrest. Echo with LVEF within 90 days. Not within 40 days of MI or 90 days of revascularization. Must document current GDMT medications and doses.

Documentation checklist

✓Echocardiogram with LVEF within 90 days
✓EKG or rhythm monitoring documenting arrhythmia (if secondary prevention)
✓NYHA functional class assessment
✓Current medication list with doses confirming GDMT
✓Documentation of primary vs. secondary prevention indication

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 33249

Office (non-facility)

$797.95

Facility

$797.95

Total RVUs (office)

23.89

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 33249 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Echocardiogram with LVEF within 90 days, EKG or rhythm monitoring documenting arrhythmia (if secondary prevention), NYHA functional class assessment….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 33249?: Yes. Anthem requires prior authorization for CPT 33249 (Cardiac device procedures including insertion of left ventricular pacing electrode and insertion/replacement of permanent implantable defibrillator system) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 33249?: Echocardiogram with LVEF within 90 days; EKG or rhythm monitoring documenting arrhythmia (if secondary prevention); NYHA functional class assessment; Current medication list with doses confirming GDMT; Documentation of primary vs. secondary prevention indication
How much does Medicare pay for CPT 33249 in 2026?: In 2026, the national Medicare allowable for CPT 33249 is $797.95 in an office setting and $797.95 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 33249?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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CPT 33249 prior authorization by payer

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