Policy
Subject
Index Number
Section
Subsection
Category
Contact
Last Review
Next Review
Heart Failure – Remote Monitoring
MedM-10.823
Medical Management
General
Departmental
Linda Daube
9/15/2015
09/2016
References
Not Applicable
Applicable To
This Medical Policy provides assistance in interpreting Gundersen Health Plan benefit provisions. It
does not constitute medical advice. When deciding coverage, the enrollee specific document must be
referenced. The terms of an enrollee’s document (Certificate of Coverage (COC) or Summary Plan
Description (SPD)) may differ greatly from this Medical Policy. In the event of a conflict, the enrollee’s
specific benefit document supersedes this Medical Policy. All reviewers must first identify enrollee
eligibility, any federal or state regulatory requirements, and the plan benefit coverage prior to use of
this Medical Policy. Other Policies and Coverage Determination Guidelines may apply. GHP reserves
the right, in its sole discretion, to modify its Policies and Guidelines as necessary.
Detail
Not Applicable
Implementation
Heart failure requires continuous management. More recently acute heart failure events are managed
in the outpatient setting. Readmission rate has been a commonly used metric for assessing heart failure.
As heart failure progresses fatigue, breathing problems and other complications become more common.
Remote monitoring is now available to assist with the management of heart failure patients.
CardioMEMS, as remote monitoring device for heart failure patients will be approved for coverage when
all of the following are met:
1. Diagnosis of NYHA Class III heart failure
2. Inpatient hospitalization within the last 12 months for a diagnosis of heart failure
3. Medically stable for outpatient surgery
4. Ability to be compliant with downloading instructions
5. Ordered by a Board Certified Cardiologist who has performed an evaluation
Coverage is limited to one per lifetime.
Coverage is limited to two downloads per month.
MedM-10.823 |Heart Failure – Remote Monitoring
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Policy
EXCLUSIONS:
1. NYHA Class I,II or IV heart failure
2. Unclassified heart failure
3. Inability to comply with downloading instructions
4. Institutionalized (SNF resident)
5. Replacement of device
6. Smokers must document complete smoking cessation with appropriate test.
References:
CardioMEMS Heart Failure Remote Monitoring Device, Technology Brief. The Advisory Board
Company. March 2015. pp 1-16.
CardioMEMS Technology Fact Sheet, St. Jude Medical. N.p., n.d. Web. Oct 8, 2014.
US Department of Health and Human Resources, FDA. RE:CardioMEMS HF System. May 28,
2014.
2015 St. Jude Medical Reimbursement Guide. CardioMEMS HF System. January 1, 2015.
Remote Cardiac Monitoring, Hayes, Inc. Web. October 22, 2015.
Heart Failure Fact Sheet. Division for Heart Disease and Stroke Prevention. Centers for Disease
Control and Prevention. Dec 3, 2013. Web. October 22, 2015.
RELATED POLICIES
ATTACHMENTS
COMMITTEE APPROVAL
Medical Directors Committee
10/28/15
UM Subcommittee
9/15/15
REVISION DATES
MedM-10.823 |Heart Failure – Remote Monitoring
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