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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 state that: 
A.   General 
Permanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted devices that send 
electrical stimulation to the heart through one or more implanted leads. They are often classified by the number 
of chambers of the heart that the devices stimulate (pulse or depolarize). Single chamber pacemakers typically 
target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and 
the right ventricle. 
The implantation procedure is typically performed under local anesthesia and requires only a brief 
hospitalization. A catheter is inserted into the chest and the pacemakers leads are threaded through the catheter 
to the appropriate chamber(s) of the heart. The surgeon then makes a small pocket in the pad of the flesh 
under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with 
stitches. 
The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to 
conclude that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and 
necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and 
second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly 
attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart 
failure, dizziness, or confusion). 
Indications and Limitations of Coverage 
 
B.  Nationally Covered Indications 
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. 
C.  Nationally Non-Covered Indications 
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. 
D.  Other 
Medicare Administrative Contractors will determine coverage under section 1862(a)(1)(A) of the Social 
Security Act for any other indications for the implantation and use of single chamber or dual chamber cardiac 
pacemakers that are not specifically addressed in this national coverage determination. 
You can find this rule at the Medicare National Coverage Determination (NCD) 20.8.3: Cardiac Pacemakers: 
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers. 
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.