SAMPLE PRIOR AUTHORIZATION LETTER
Cardiac Implant Devices
______________________________________________________________________________
PLEASE NOTE: This letter is intended as an example for your consideration and may not
include all the information necessary to support your prior authorization request. The requesting
facility is entirely responsible for ensuring the accuracy, adequacy, and supportability of all the
information provided. As a reminder, Medicare does not preauthorize medical procedures. It is
recommended that you contact your patient’s insurance company to obtain specific
inclusion/exclusion criteria.
[Date]
Attention: Surgery Preauthorization Department
[Insurance Company address]
Re:
Patient Name: ____________________
Policy Holder Name: _______________
Patient ID #: _______________________
Policy, Group, or Claim # ____________
Dear Madam/Sir:
This letter is to request approval for the surgery, hospitalization, and post-surgical care
associated with the planned implantation of a [select one] Cardiac Resynchronization Therapy
defibrillator (CRT-D); Implantable Cardioverter-Defibrillator or Pacemaker for (patient name).
This patient is schedule for surgery on [insert date].
CRT-D Therapy
Boston Scientific Cardiac Resynchronization Therapy Defibrillators (CRT-Ds)
are indicated for patients with heart failure who receive stable optimal pharmacologic
therapy (OPT) for heart failure and who meet any one of the following classifications:
• Moderate to severe heart failure (NYHA Class III-IV) with EF ≤ 35% and QRS
duration ≥ 120 ms
• Left bundle branch block (LBBB) with QRS duration ≥ 130 ms, EF ≤ 30%, and mild
(NYHA Class II) ischemic or nonischemic heart failure or asymptomatic (NYHA Class I)
ischemic heart failure
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 1
ICD Therapy
Boston Scientific ICDs are intended to provide ventricular antitachycardia pacing and ventricular
defibrillation for automated treatment of life-threatening ventricular arrhythmias.
CRT-P Therapy
Boston Scientific cardiac resynchronization pacemakers (CRT-Ps) are indicated for patients with
moderate to severe heart failure (NYHA Class III/IV) including left ventricular dysfunction (EF
≤ 35%) and QRS duration ≥ 120 ms and remain symptomatic despite stable optimal
pharmacological therapy (OPT) for heart failure.
Atrial tracking modes are also indicated for patients who may benefit from maintenance
of AV synchrony. Adaptive-rate pacing is indicated for patients exhibiting chronotropic
incompetence and who would benefit from increased pacing rates concurrent with increases in
physical activity.
Pacemaker Therapy
Boston Scientific pacemakers are indicated for treatment of the following conditions:
• Symptomatic paroxysmal or permanent second- or third-degree AV block
• Symptomatic bilateral bundle branch block
• Symptomatic paroxysmal or transient sinus node dysfunction with or without
associated AV conduction disorders (i.e., sinus bradycardia, sinus arrest, sinoatrial
[SA] block
• Bradycardia-tachycardia syndrome, to prevent symptomatic bradycardia or some
forms of symptomatic tachyarrhythmias
• Neurovascular (vaso-vagal) syndromes or hypersensitive carotid sinus syndromes
Adaptive-rate pacing is indicated for patients exhibiting chronotropic incompetence and
who may benefit from increased pacing rates concurrent with increases in minute
ventilation and/or level of physical activity.
Dual-chamber and atrial tracking modes are also indicated for patients who may benefit from
maintenance of AV synchrony.
Dual chamber modes are specifically indicated for treatment of the following:
• Conduction disorders that require restoration of AV synchrony, including varying
degrees of AV block
• VVI intolerance (i.e., pacemaker syndrome) in the presence of persistent sinus
rhythm
• Low cardiac output or congestive heart failure secondary to bradycardia
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 2
I am requesting approval to implant a Boston Scientific [insert name of device] in order to
provide continued clinical benefit to my patient. The [insert name of device] is FDA approved
for use in this patient.
This implant/replacement procedure is consistent with the current Medicare National Coverage
Determination for ICDs and current published clinical guidelines [Select from the links below
and include any applicable guidelines or specific clinical indications for your patient].
Click on the link below to access the CMS NCD for Implantable Automatic Defibrillators:
http://cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=110&ncdver=3&CoverageSelection=National&KeyWord=implantable+def
ibrillators&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&
Click on the link below to access the CMS NCD for Pacemakers:
http://cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=238&ncdver=2&SearchType=Advanced&CoverageSelection=National&N
CSelection=NCD&KeyWord=pacemakers&KeyWordLookUp=Title&KeyWordSearchType=Ex
act&kq=true&bc=IAAAABAAAAAA&
Click on the link below to access the HRS/ACCF Consensus Statement on Pacemaker Device
and Mode Selection-June 2012:
http://www.hrsonline.org/ClinicalGuidance/upload/-Pacemaker-Device-Mode-SelectionConsensus-Statement.pdf
Click on the link below to access the ACC/AHA/HRS 2008 Guidelines for Devices Based
Therapy:
http://content.onlinejacc.org/article.aspx?articleid=1138927
Click on the link below to access the HFSA CRT Guideline Update for CRT therapy:
http://download.journals.elsevierhealth.com/pdfs/journals/10719164/PIIS1071916411013224.pdf
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 3
I plan to use the following codes to bill for professional and facility services [Note: The sample
list of codes below does not represent a complete list of all CPT® codes that may be used. Please
refer to the most current version of the AM’s CPT code book for additional code(s) selection.
Select the appropriate codes from the examples below that best describe the completed
procedure(s). It may be helpful to delete any procedure codes that do not apply to a particular
situation.]
CRT-D / ICD CPT® Procedure Codes
33240
Insertion of pacing cardioverter-defibrillator pulse generator only; with
existing single lead
33230
Insertion of pacing cardioverter-defibrillator pulse generator only; with
existing dual leads
33231
Insertion of pacing cardioverter-defibrillator pulse generator only; with
existing multiple leads
33241
Removal of pacing cardioverter-defibrillator pulse generator only
33249
Insertion or replacement of permanent pacing cardioverter-defibrillator
system with transvenous lead(s), single or dual chamber
Removal of pacing cardioverter-defibrillator pulse generator with
replacement of pacing cardioverter-defibrillator pulse generator; single lead
system
Removal of pacing cardioverter-defibrillator pulse generator with
replacement of pacing cardioverter-defibrillator pulse generator; dual lead
system
Removal of pacing cardioverter-defibrillator pulse generator with
replacement of pacing cardioverter-defibrillator pulse generator; multiple
lead system
Revision of skin pocket for cardioverter-defibrillator
33262
33263
33264
33233
ICD Defibrillator Lead CPT Procedure Codes
33215
Repositioning of previously implanted transvenous pacemaker or pacing
cardioverter-defibrillator (right atrial or right ventricular) electrode
33216
Insertion of a single transvenous electrode, permanent pacemaker or
cardioverter-defibrillator
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 4
33217
Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverterdefibrillator
33218
Repair of single transvenous electrode, permanent pacemaker or pacing
cardioverter-defibrillator
33220
Repair of 2 transvenous electrodes, permanent pacemaker or pacing
cardioverter-defibrillator
33224
Insertion of pacing electrode, cardiac venous system, for left ventricular
pacing, with attachment to previously placed pacemaker or pacing
cardioverter-defibrillator pulse generator (including revision of pocket,
removal insertion, and/or replacement of existing generator)
33225
Insertion of pacing electrode, cardiac venous system, for left ventricular
pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker
pulse generator (including upgrade to dual chamber system and pocket
revision) (List separately in addition to code for primary procedure)
33226
Repositioning of previously implanted cardiac venous system (left
ventricular) electrode (including removal, insertion and/or replacement of
existing generator)
33243
Removal of single or dual chamber pacing cardioverter-defibrillator
electrode(s); by thoracotomy
33244
Removal of single or dual chamber pacing cardioverter-defibrillator
electrode(s); by transvenous extraction
CRT-P / Pacemaker CPT Procedure Codes
33206
33212
Insertion of new or replacement of permanent pacemaker with transvenous
electrode(s); atrial
Insertion of new or replacement of permanent pacemaker with transvenous
electrode(s); ventricular
Insertion of new or replacement of permanent pacemaker with transvenous
electrode(s); atrial and ventricular
Insertion of pacemaker pulse generator only; with existing single lead
33213
Insertion of pacemaker pulse generator only; with existing dual lead
33221
Insertion of pacemaker pulse generator only; with existing multiple lead
33207
33208
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 5
33214
Upgrade of implanted pacemaker system, conversion of single chamber
system to dual chamber system (includes removal of previously placed pulse
generator, testing of existing lead, insertion of new lead, insertion of new
pulse generator)
33222
Revision or relocation of skin pocket for pacemaker
33233
Removal of permanent pacemaker pulse generator only
33227
Removal of permanent pacemaker pulse generator with replacement of
pacemaker pulse generator; single lead system
33228
Removal of permanent pacemaker pulse generator with replacement of
pacemaker pulse generator; dual lead system
33229
Removal of permanent pacemaker pulse generator with replacement of
pacemaker pulse generator; multiple lead system
Pacemaker Lead Procedure CPT Codes
33215
Repositioning of previously implanted transvenous pacemaker or pacing
cardioverter-defibrillator (right atrial or right ventricular) electrode
33216
Insertion of a single transvenous electrode, permanent pacemaker or
cardioverter-defibrillator
Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverterdefibrillator
33217
33218
Repair of single transvenous electrode, permanent pacemaker or pacing
cardioverter-defibrillator
33220
Repair of 2 transvenous electrodes, permanent pacemaker or pacing
cardioverter-defibrillator
33224
Insertion of pacing electrode, cardiac venous system, for left ventricular
pacing, with attachment to previously placed pacemaker or pacing
cardioverter-defibrillator pulse generator (including revision of pocket,
removal insertion, and/or replacement of existing generator)
33225
Insertion of pacing electrode, cardiac venous system, for left ventricular
pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 6
pulse generator (including upgrade to dual chamber system and pocket
revision) (List separately in addition to code for primary procedure)
33226
Repositioning of previously implanted cardiac venous system (left
ventricular) electrode (including removal, insertion and/or replacement of
existing generator)
33234
Removal of transvenous pacemaker electrode(s); single lead system, atrial or
ventricular
33235
Removal of transvenous pacemaker electrode(s); dual lead system
EP Evaluation of CRT-D / ICD System
93641-26
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement; with testing of single or dual
chamber pacing cardioverter-defibrillator pulse generator
®
CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are
not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
__(Patient name)__
is medically appropriate for this procedure, and we request that
approval be granted for the surgery and all related services as soon as possible. Please fax your
approval to my office at the following number (fax #)_
_ or contact me with
additional questions that I may clarify. I can be reached at (tele #
.
Sincerely,
[Physician Name]
[Practice Name]
[Phone Number]
The following medical record documentation is provided to support the medical necessity of
performing this service.
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 7
Enclosures
 History and physical
 MD order and progress notes
 Pertinent test reports with written interpretation
 Office/progress notes
DISCLAIMER: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources
and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit
accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery
of any services and to submit appropriate codes, charges and modifiers for services that are rendered. Boston Scientific recommends that you
consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston
Scientific does not promote the use of its products outside their FDA-approved labeling. Payer policies will vary and should be verified prior to
treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used
codes and are not intended to be an all-inclusive list. Providers are responsible for making appropriate decisions related to coding and
reimbursement submissions. We recommend consulting your relevant manuals for appropriate coding options.
CRM-101811-AA AUG2012
Page 8