Medicare AdvantageCoverageMedium impact
Ventricular Assist Device, Total Artificial Heart - Medicare Advantage (Revised)
Humana·Cardiology, Cardiothoracic Surgery, Critical Care +1 more·Medicare Advantage
Effective date
Aug 3, 2026
We identified it
Aug 13, 2026
Summary
This is a revised Medicare Advantage policy for Ventricular Assist Devices (VADs) and Total Artificial Hearts (TAHs) effective 08/03/2026. The policy clarifies coverage criteria for Left VADs (LVADs), Percutaneous VADs (pVADs), and TAHs, referencing CMS National Coverage Determination 20.9.1 and applicable Local Coverage Articles. Key exclusions include RVADs, BiVADs, patients under 18, complex congenital heart disease, and acute heart failure without chronic history. Billing teams must ensure claims comply with specific medical necessity criteria and facility credentialing requirements.
Action Required
By 08/03/2026: Billing team must update claim submission protocols to enforce VAD/TAH coverage criteria per this revised policy. (1) For LVAD claims (CPT 33975, 33979, 93750): reference CMS NCD 20.9.1 for medical necessity validation. (2) For pVAD claims (CPT 33990, 33991, 33995): verify FDA approval, confirm external counterpulsation (IABP) is insufficient, and confirm diagnosis meets criteria (cardiogenic shock, intra/post-operative circulatory complications, or severe decompensated HF with organ failure). (3) For TAH destination therapy (CPT 33927): confirm via CMS NCD 20.9.1 and LCA A59657. (4) For TAH bridge-to-transplant (CPT 33927): verify patient is transplant-eligible, awaiting transplant, has imminent death risk from biventricular failure, and is ineligible for VAD placement. (5) For VAD replacements (CPT 33976, 33981, 33982, 33983): refer to Medicare Benefit Policy Manual Pub. 100-02 Chapter 15 Section 120. (6) Verify treating facility is CMS-credentialed via http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/VAD-Destination-Therapy-Facilities.html. (7) Flag and deny claims for excluded populations: patients under 18, RVADs, BiVADs, complex congenital heart disease, or acute HF without chronic history. Update billing software edits, prior authorization templates, and provider guidance materials to reflect these specific requirements. Claims lacking required documentation or from non-credentialed facilities will be denied.