Medical Policy:
Implantable Pulmonary Artery Pressure Measurement Device
Diagnostic Medical
Effective Date:
October 8, 2018
Issued Date:
October 8, 2018
Last Revision Date:
October 2018
Annual Review:
October 2018

The CardioMEMS™ Heart Failure (HF) System is a wireless pulmonary arterial (PA) pressure monitoring system. It measures PA pressures from a battery free sensor in the distal pulmonary artery. An electronic system transmits the generated data to a secure network where it is available for the interpretation by the treating physician.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

The CardioMEMS™ HF System may be considered medically necessary for individuals that meet ALL of the following indications:

  • Diagnosis of New York Heart Association (NYHA) Class III HF symptoms predominantly present over the previous months, despite maximally tolerated guideline directed medical and device therapies; and
  • At least one (1) HF related hospitalization within the previous 12 months; and
  • Able to take dual antiplatelet or anticoagulants for one (1) month post-implant; and
  • Greater than or equal to 18 years of age; and
  • Diagnosis of HF greater than or equal to three (3) months, with either preserved or reduced left ventricular ejection fraction; and
  • Body mass index (BMI) of less than or equal to 35; or 
  • If BMI is greater than 35, a measurement of chest circumference at axillary level is required.  If the chest circumference is greater than 165 cm, the sensor should not be implanted due to poor signal strength; and
  • PA branch diameter sized between 7 mm and 15 mm.

Monitoring must occur at least once weekly in all individuals implanted with CardioMEMS™. Weekly monitoring is acceptable as long as the individual maintains acceptable PA pressure (opti-volemic).

If PA pressure is not opti-volemic:

  • Monitoring must occur at least TWO-THREE times per week until opti-volemic in cases where the individual has elevated PA pressure (hyper-volemic) or low PA pressure (hypo-volemic); and
  • Monitoring must occur at least TWO-THREE times per week until pressure stabilizes in cases where the individual receives medication modifications or exhibits significant deviations in trend data.

The CardioMEMS™ HF System is considered experimental/investigational and, therefore, non-covered for any other indication. The safety and/or effectiveness cannot be established by review of the published peer-reviewed literature.




NOTE: Recommendation per FDA label.

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Implantable pulmonary artery pressure measurement device is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

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    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.