Cardiac Contractility Modulation Therapy

Policy ID: S-278-002

Section: Surgery

Effective Date: March 06, 2023

Revised Date: March 04, 2024

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Cardiac contractility modulation (CCM) therapy is a United States Food and Drug Administration approved device utilized for individuals with congestive heart failure. This therapy delivers an electrical signal to the right side of the heart via an implantable pulse generator and alters the strength of the contraction. The CCM therapy has no pacemaker of defibrillator functions.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

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

Procedure Codes

0408T

0409T

0410T

0411T

0413T

0414T

0417T

0418T

Outpatient HCPCS (C Code)

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

C1824

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 01-26-2023 New Policy - Effective March 06, 2023

Internal Medical Policy Committee 1-16-2024 Annual review - no changes in criteria

Internal Medical Policy Committee 1-14-2025 Annual review - no changes in criteria

Added Policy Application

Internal Medical Policy Committee 5-13-2025 Annual review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-278-001

Section: Surgery

Effective Date: March 06, 2023

Revision Effective Date: March 04, 2024

Last Reviewed: January 14, 2025

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

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

Procedure Codes

0408T

0409T

0410T

0411T

0413T

0414T

0417T

0418T

Outpatient HCPCS (C Code)

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

C1824

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 01-26-2023 New Policy - Effective March 06, 2023

Internal Medical Policy Committee 1-16-2024 Annual review - no changes in criteria

Internal Medical Policy Committee 1-14-2025 Annual review - no changes in criteria

Added Policy Application

Medical Policies Quick Search

Cardiac Contractility Modulation Therapy

Description

Policy Application

Criteria

Procedure Codes

Outpatient HCPCS (C Code)

Policy Application

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Outpatient HCPCS (C Code)

Policy Application

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer