About this policy
Percutaneous insertion of an endovascular cardiac assist device requires documentation supporting the diagnosis of the following 3 life-threatening situations when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient: Cardiogenic shock ICD-10-CM code R57.0; or Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; or Complications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 33990 | HCPCS | Covered |
| 33991 | HCPCS | Covered |
| 33992 | HCPCS | Covered |
| 33993 | HCPCS | Covered |
| 33995 | HCPCS | Covered |
| 33997 | HCPCS | Covered |
| I50.21 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I97.110 | ICD10CM | Covered |
| I97.111 | ICD10CM | Covered |
| I97.130 | ICD10CM | Covered |
| I97.131 | ICD10CM | Covered |
| I97.790 | ICD10CM | Covered |