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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and 
hypothermia, 
2. Asymptomatic first degree atrioventricular block, 
3. Asymptomatic sinus bradycardia, 
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia, 
6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of 
the His Bundle (a component of the electrical conduction system of the heart), 
7. Syncope of undetermined cause, 
8. Bradycardia during sleep, 
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch 
block) without syncope or other symptoms of intermittent atrioventricular block, 
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-
blocker drug therapy, 
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 
12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not 
associated with a reasonable likelihood that pacing needs will become prolonged. 
Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD ? Group II (Attest with Modifier 
- KX) 
- Atrioventricular block, unspecified (Symptomatic) (I44.30) 
- First-degree atrioventricular block (Symptomatic with PR interval more than 300 milliseconds) (I44.0) 
- Left bundle branch block, other or unspecified (I44.7) 
- Right bundle branch block, unspecified or other (I45.10 / I45.19) 
- Bundle branch block, unspecified (I45.10 or I45.19) 
- Right bundle branch block and left posterior fascicular block (I45.2) 
- Right bundle branch block and left anterior fascicular block (I45.2) 
o Other bilateral bundle branch block (I45.2) 
o Bifascicular block (I45.2) 
o Trifascicular block (I45.3) 
- Supraventricular tachycardias in which a pacemaker is specifically for control of the tachycardia (I47.1 
or I47.9) 
- Paroxysmal supraventricular tachycardia/supraventricular tachycardia (SVT that is reproducibly 
terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce 
intolerable side effects) (I47.1 / I47.9) 
 
 
- Atrial fibrillation/atrial fibrillation, persistent; unspecified atrial fibrillation (I48.1 / I48.91) with 
symptomatic bradycardia due to necessary medical therapy 
- Atrial flutter/atrial flutter, typical/atypical/unspecified (I48.3 / I48.4 / I48.92 with symptomatic 
bradycardia due to necessary medical therapy 
- Hypersensitive carotid sinus syndrome and neurocardiogenic syncope (Syncope without clear, 
provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer or for 
significantly symptomatic neurocardiogenic syncope associated with bradycardia documented 
spontaneously or at the time of tilt-table testing (G90.01) 
You can find this rule in the Local Coverage Article: Billing and Coding: Single Chamber and Dual Chamber 
Permanent Cardiac Pacemakers (A54909) effective May 7, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.