Author: Clinical Policy and Programs
Effective March 1, 2018, North Carolina Medicaid has revised Clinical Policy 11C, Ventricular Assist Devices, as follows:
- Prior authorization is removed for CPT codes 33975, 33976, 33977, 33978, 33979, and 33980
- PA requirements are removed for ICD 10 codes 02HA0QZ, 02HA0RS, 02HA3QZ, 02HA3RS, 02HA3RZ, 02HA4QZ, 02HA4RZ, 02PA0RZ, 02PA3RZ, 02PA4RZ, 02UA0JZ, 02UA3JZ, 02UA4JZ, 5A02116 and 5A02216.
- Coverage criteria under Section 3.0 and non-coverage criteria under Section 4.0 are updated
- Limitations listed under Section 5.3 are added to provide criteria when a replacement VAD or a component of the VAD is considered medically necessary.
The revised policy is available on Medicaid’s Ventricular Assist Devices Clinical Coverage Policy web page.
Clinical Policy and Programs
DMA, 919-855-4260