CMS Pub. 100-03, ch. 1, § 20.8.1

Medicare covers a variety of services for the post-implant follow-up and evaluation of

implanted cardiac pacemakers. The following guidelines are designed to assist A/B

MACs in identifying and processing claims for such services.

NOTE: These new guidelines are limited to lithium battery-powered pacemakers,

because mercury-zinc battery-powered pacemakers are no longer being manufactured and

virtually all have been replaced by lithium units. A/B MACs still receiving claims for

monitoring such units should continue to apply the guidelines published in 1980 to those

units until they are replaced.

There are two general types of pacemakers in current use - single-chamber pacemakers

which sense and pace the ventricles of the heart, and dual-chamber pacemakers which

sense and pace both the atria and the ventricles. These differences require different

monitoring patterns over the expected life of the units involved. One fact of which A/B

MACs should be aware is that many dual-chamber units may be programmed to pace

only the ventricles; this may be done either at the time the pacemaker is implanted or at

some time afterward. In such cases, a dual-chamber unit, when programmed or

reprogrammed for ventricular pacing, should be treated as a single-chamber pacemaker in

applying screening guidelines.

The decision as to how often any patient’s pacemaker should be monitored is the

responsibility of the patient’s physician who is best able to take into account the

condition and circumstances of the individual patient. These may vary over time,

requiring modifications of the frequency with which the patient should be monitored. In

cases where monitoring is done by some entity other than the patient’s physician, such as

a commercial monitoring service or hospital outpatient department, the physician’s

prescription for monitoring is required and should be periodically renewed (at least

annually) to assure that the frequency of monitoring is proper for the patient. Where a

patient is monitored both during clinic visits and transtelephonically, the A/B MAC

should be sure to include frequency data on both types of monitoring in evaluating the

reasonableness of the frequency of monitoring services received by the patient.

Since there are over 200 pacemaker models in service at any given point, and a variety of

patient conditions that give rise to the need for pacemakers, the question of the

appropriate frequency of monitoring is a complex one. Nevertheless, it is possible to

develop guidelines within which the vast majority of pacemaker monitoring will fall and

A/B MACs should do this, using their own data and experience, as well as the frequency

guidelines which follow, in order to limit extensive claims development to those cases

requiring special attention.