Medicare Advantage

Medical Policy

Title:

Ventricular Assist Devices (VADs)

Policy #:

MA11.011i

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

POSTCARDIOTOMY
A US Food and Drug Administration (FDA)-approved ventricular assist device (VAD) is considered medically necessary and, therefore, covered, when both of the following criteria are met:

The VAD is being used in accordance with the FDA labeling.
The VAD is being used for support of blood circulation postcardiotomy.

ADVANCED HEART FAILURE

A left ventricular assist device (LVAD) that is FDA approved for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support in individuals with heart failure is considered medically necessary and, therefore, covered when the following criteria are met:

The individual has New York Heart Association (NYHA) Class IV heart failure, left ventricular ejection fraction (LVEF) of 25% or less, and are inotrope dependent OR the individual has a cardiac index (CI) of less than 2.2 L/min/m², while not on inotropes, AND meets one of the following:

On optimal medical management (OMM), based on current heart failure practice guidelines for at least 45 of the past 60 days and are failing to respond; OR
Has advanced heart failure for at least 14 days and are dependent on an intra-aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days.

Individuals receiving a VAD must be managed by an explicitly identified, cohesive, multidisciplinary team of medical professionals with the appropriate qualifications, training, and experience. The team members must be based at the facility and must include individuals with experience working with individuals before and after placement of a VAD.

Facility criteria must be met.

A list of approved facilities and their approval dates are listed and maintained on the Centers for Medicare & Medicaid Services (CMS) coverage website (http://www.cms.hhs.gov/MedicareApprovedFacilitie/VAD/list.asp#TopOfPage) and published in the Federal Register.

All other indications for the use of VADs not otherwise listed remain noncovered, except in the context of a Category B investigational device exemption clinical trial.

SUPPLIES IN THE OUTPATIENT SETTING

VAD replacement supplies, as defined by the coding table in this policy, for use in the outpatient setting are eligible for separate reimbursement when the individual meets the medical necessity criteria for a VAD that has been approved by the FDA for use in the outpatient setting.

The HCPCS codes in the coding table represent replacement equipment, with the exception of Q0478, Q0507, and Q0508, which are also eligible for separate reimbursement when the individual meets the medical necessity criteria for a VAD that has been approved by the FDA for use in the outpatient setting. HCPCS codes Q0507 and Q0508 can represent initial or replacement equipment, and requests for authorization must include a detailed description of the supply or accessory being billed under Q0507 or Q0508. Reimbursement is limited to supplies and accessories for use with an external or implanted VAD, and not for a maintenance service for such equipment and supplies.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

When submitting a claim, HCPCS codes Q0507 and Q0508 should be reported for miscellaneous supplies or accessories used with a VAD. HCPCS Q0509 should not be reported.

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, artificial hearts and ventricular assist devices (VADs) are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

A ventricular assist device (VAD) or left ventricular assist device (LVAD) is surgically attached to one or both intact ventricles and is used to assist a damaged or weakened native heart in pumping blood. Improvement in the performance of the native heart may allow the device to be removed. VADs are used for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support in individuals with advanced heart failure or for support of blood circulation

postcardiotomy, which is the period following open-heart surgery.

VADs used for the indications listed on this policy are covered only if they have received approval from the US Food and Drug Administration (FDA) for

that purpose, and the VADs are used according to the FDA-approved labeling instructions.

References

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). June 2021.

Available at: MM12290 (cms.gov). Accessed January 29, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Ventricular Assist Devices (20.9.1). 12/01/2020. [CMS website]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=360&ncdver=2&bc=CAAAAAAAAAAA. Accessed January 29, 2026.

Coding

CPT Procedure Code Number(s)

33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33992, 33993, 33995, 33997, 93750

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

Q0477 Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0478 Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type

Q0479 Power module for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0480 Driver for use with pneumatic ventricular assist device, replacement only

Q0481 Microprocessor control unit for use with electric ventricular assist device, replacement only

Q0482 Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only

Q0483 Monitor/display module for use with electric ventricular assist device, replacement only

Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0485 Monitor control cable for use with electric ventricular assist device, replacement only

Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only

Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only

Q0488 Power pack base for use with electric ventricular assist device, replacement only

Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only

Q0490 Emergency power source for use with electric ventricular assist device, replacement only

Q0491 Emergency power source for use with electric/pneumatic ventricular assist device, replacement only

Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement only

Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only

Q0494 Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0496 Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0499 Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only

Q0500 Filters for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0501 Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0502 Mobility cart for pneumatic ventricular assist device, replacement only

Q0503 Battery for pneumatic ventricular assist device, replacement only, each

Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type

Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device

Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device

THE FOLLOWING HCPCS CODE SHOULD NOT BE REPORTED

Q0509 Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.011i

10/01/2026

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the ICD-10 code update, effective 10/01/2026.

The following ICD-10 codes have been terminated and removed from this policy:

I42.0 Dilated cardiomyopathy

I42.8 Other cardiomyopathies

I49.8 Other specified cardiac arrhythmias

The following ICD-10 codes have been added to this policy:

I42.00 Dilated cardiomyopathy, unspecified

I42.01 Familial-genetic dilated cardiomyopathy

I42.09 Other dilated cardiomyopathy

I42.81 Arrhythmogenic cardiomyopathy

I42.89 Other cardiomyopathies not elsewhere classified

I47.22 Catecholaminergic polymorphic ventricular tachycardia [CPVT]

I49.81 Brugada syndrome

I49.82 Ventricular bigeminy

I49.89 Other specified cardiac arrhythmias not elsewhere classified

Revisions From MA11.011h:

04/01/2026	This policy has been reviewed and reissued to communicate the Company’s continuing position on ventricular assist devices (VADs).
04/21/2025	This version of the policy will become effective on 04/01/2025. The following criteria have been added to this policy in accordance with the Centers for Medicare & Medicaid Services NCD 20.9.1 Ventricular assist devices: Individuals receiving a VAD must be managed by an explicitly identified, cohesive, multidisciplinary team of medical professionals with the appropriate qualifications, training, and experience. The team members must be based at the facility and must include individuals with experience working with individuals before and after placement of a VAD. In addition, a billing requirement was added to clarify the HCPCS codes that should be reported when submitting a claim for miscellaneous supplies or accessories used with a ventricular assist device.

04/01/2026

This policy has been reviewed and reissued to communicate the Company’s continuing position on ventricular assist devices (VADs).

04/21/2025

This version of the policy will become effective on 04/01/2025.

The following criteria have been added to this policy in accordance with the Centers for Medicare & Medicaid Services NCD 20.9.1 Ventricular assist devices:

In addition, a billing requirement was added to clarify the HCPCS codes that should be reported when submitting a claim for miscellaneous supplies or accessories used with a ventricular assist device.

Revisions From MA11.011g:

05/01/2024	The policy has been reviewed and reissued to communicate the Company’s continuing position on Ventricular Assist Devices (VADs).
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
10/01/2023	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the ICD-10 code update, effective 10/01/2023. The following ICD-10 codes have been termed and removed from this policy: I24.8 Other forms of acute ischemic heart disease I47.1 Supraventricular tachycardia The following ICD-10 codes have been added to this policy: I24.81 Acute coronary microvascular dysfunction I24.89 Other forms of acute ischemic heart disease I25.85 Chronic coronary microvascular dysfunction I47.10 Supraventricular tachycardia, unspecified I47.11 Inappropriate sinus tachycardia, so stated I47.19 Other supraventricular tachycardia The following ICD-10 code narrative has been revised: I25.112 FROM: Atherosclerosic heart disease of native coronary artery with refractory angina pectoris TO: Atherosclerotic heart disease of native coronary artery with refractory angina pectoris

05/01/2024

The policy has been reviewed and reissued to communicate the Company’s continuing position on Ventricular Assist Devices (VADs).

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

10/01/2023

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the ICD-10 code update, effective 10/01/2023.

The following ICD-10 codes have been termed and removed from this policy:

I24.8 Other forms of acute ischemic heart disease

I47.1 Supraventricular tachycardia

The following ICD-10 codes have been added to this policy:

I24.81 Acute coronary microvascular dysfunction

I24.89 Other forms of acute ischemic heart disease

I25.85 Chronic coronary microvascular dysfunction

I47.10 Supraventricular tachycardia, unspecified

I47.11 Inappropriate sinus tachycardia, so stated

I47.19 Other supraventricular tachycardia

The following ICD-10 code narrative has been revised: I25.112

FROM: Atherosclerosic heart disease of native coronary artery with refractory angina pectoris

TO: Atherosclerotic heart disease of native coronary artery with refractory angina pectoris

Revisions From MA11.011f:

02/22/2023	The policy has been reviewed and reissued to communicate the Company’s continuing position on Ventricular Assist Devices (VADs).
10/01/2022	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the ICD-10 code update, effective 10/01/2022. The following ICD-10 codes have been termed and removed from this policy: I34.8 Other nonrheumatic mitral valve disorders I47.2 Ventricular tachycardia The following ICD-10 codes have been added to this policy: I20.2 Refractory angina pectoris I25.112 Atherosclerosic heart disease of native coronary artery with refractory angina pectoris I25.702 Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris I25.712 Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris I25.722 Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris I25.732 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris I25.752 Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris I25.762 Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris I25.792 Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris I34.81 Nonrheumatic mitral (valve) annulus calcification I34.89 Other nonrheumatic mitral valve disorders I47.20 Ventricular tachycardia, unspecified I47.21 Torsades de pointes I47.29 Other ventricular tachycardia

02/22/2023

The policy has been reviewed and reissued to communicate the Company’s continuing position on Ventricular Assist Devices (VADs).

10/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the ICD-10 code update, effective 10/01/2022.

The following ICD-10 codes have been termed and removed from this policy:

I34.8 Other nonrheumatic mitral valve disorders

I47.2 Ventricular tachycardia

The following ICD-10 codes have been added to this policy:

I20.2 Refractory angina pectoris

I25.112 Atherosclerosic heart disease of native coronary artery with refractory angina pectoris

I25.702 Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris

I25.712 Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris

I25.722 Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris

I25.732 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris

I25.752 Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris

I25.762 Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris

I25.792 Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris

I34.81 Nonrheumatic mitral (valve) annulus calcification

I34.89 Other nonrheumatic mitral valve disorders

I47.20 Ventricular tachycardia, unspecified

I47.21 Torsades de pointes

I47.29 Other ventricular tachycardia

Revisions From MA11.011e:

03/09/2022	This policy has been reissued in accordance with the Company's annual review process.
12/01/2020	This version of the policy will be issued on 08/16/2021 with a retro-effective date of 12/01/2020. This policy has been updated in accordance with the Centers for Medicare & Medicaid Services (CMS) Decision Memo for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy (CAG-00453N) and National Coverage Determination (NCD 20.9.1) Ventricular Assist Devices (VADs): Coverage with Evidence Development (CED) criteria for artificial hearts was removed from this policy. Ventricular Assist Device (VAD) criteria was revised in accordance with CMS: Removes the current therapeutic intent-to-treat criteria of bridge-to-transplant (BTT) and destination therapy (DT). Extends evidence based selection criteria, that previously applied only to DT, for all LVAD procedures for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support. Modifies selection criteria to reflect the major inclusion criteria of contemporary trials. Coding: The following CPT codes have been removed from this policy: 33927, 33928, 33929 The following HCPCS code has been removed from this policy: L8698 Miscellaneous component, supply or accessory for use with total artificial heart system

03/09/2022

This policy has been reissued in accordance with the Company's annual review process.

12/01/2020

This version of the policy will be issued on 08/16/2021 with a retro-effective date of 12/01/2020.

This policy has been updated in accordance with the Centers for Medicare & Medicaid Services (CMS) Decision Memo for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy (CAG-00453N) and National Coverage Determination (NCD 20.9.1) Ventricular Assist Devices (VADs):

Coverage with Evidence Development (CED) criteria for artificial hearts was removed from this policy.

Ventricular Assist Device (VAD) criteria was revised in accordance with CMS:

Removes the current therapeutic intent-to-treat criteria of bridge-to-transplant (BTT) and destination therapy (DT).
Extends evidence based selection criteria, that previously applied only to DT, for all LVAD procedures for short-term (e.g., bridge-to-recovery and bridge-to-transplant) or long-term (e.g., destination therapy) mechanical circulatory support.
Modifies selection criteria to reflect the major inclusion criteria of contemporary trials.

Coding:

The following CPT codes have been removed from this policy:

33927, 33928, 33929

The following HCPCS code has been removed from this policy:

L8698 Miscellaneous component, supply or accessory for use with total artificial heart system

Revisions From MA11.011d:

01/01/2021

This policy has been identified for the CPT code update, effective 01/01/2021.

The following CPT code narratives have been revised in this policy:

33990, 33991, 33992, 33993

The following CPT codes have been added to this policy:

33995, 33997

Revisions From MA11.011c:

12/18/2019	This policy has been reissued in accordance with the Company's annual review process.
01/01/2019	This version of the policy will become effective 01/01/2019. The following HCPCS code has been added to this policy: L8698 Miscellaneous component, supply or accessory for use with total artificial heart system

Revisions From MA11.011b:

04/25/2018

The policy has been reviewed and reissued to communicate the Company’s continuing position on artificial hearts and ventricular assist devices (VADs)

01/01/2018

This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been added to this policy:

33927, 33928, 33929

The following CPT codes have been deleted from this policy:

0051T, 0052T, 0053T

The following HCPCS code has been added to this policy:

Q0477 Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only

Revisions From MA11.011a:

06/21/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on total artificial hearts (TAHs) and ventricular assist devices (VADs)
08/12/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on Ventricular Assist Devices (VADs). ICD-10 codes that were previously contained in Attachment A have been removed as it was not an all inclusive list.

Revisions From MA11.011:

08/19/2015	ICD-10-CM codes have been added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy. The following ICD-10 CM codes have been added to this policy: I01.2; I09.0; I09.81; I11.0; I13.0; I13.2; I40.0; I40.1; I40.8; I40.9; I41 I42.0; I42.1; I42.2; I42.3; I42.4; I42.5; I42.6; I42.7; I42.8; I42.9; I43; I46.2; I46.8; I46.9; I50.1; I50.20; I50.21; I50.22; I50.23; I50.30; I50.31; I50.32; I50.33; I50.40; I50.41; I50.42; I50.43; I50.9; I51.4; I51.5; I51.7; I51.81; I51.89; I51.9; I52; I97.0; I97.110; I97.111; I97.120; I97.121; I97.130; I97.131; I97.190; I97.191; I97.710; I97.711; I97.790; I97.791; O90.3; Q23.4; Q24.8; R57.0; T81.11XA; T81.11XD; T81.11XS; T82.518A; T82.518D; T82.518S; T82.519A; T82.519D; T82.519S; T82.528A; T82.528D; T82.528S; T82.529A; T82.529D; T82.529S; T82.598A; T82.598D; T82.598S; T82.599A; T82.599D; T82.599S; T82.7XXA; T82.7XXD; T82.7XXS; T82.867A; T82.867D; T82.867S; T82.897A; T82.897D; T82.897S; T82.9XXA; T82.9XXD; T82.9XXS; T86.20; T86.21; T86.22; T86.31; T86.32; Z76.82; Z95.1; Z95.811.
02/04/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on Artificial Hearts and Ventricular Assist Devices (VADs).
01/01/2015	This is a new policy. The following sections in the notification draft have been amended to align policy MA11.011 with National Coverage Determination (NCD).20.9 and Decision Memo for Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy (CAG-00432R): Bridge-to-Transplant Destination Therapy

Version Effective Date:

10/1/2026

Version Issued Date:

10/1/2026

Version Reissued Date:

Medicare Advantage

Medical Policy

Notification

Policy

Guidelines

Description

References

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History