Q0484 Monitor elec or comb vad repMonitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
Status E: excluded from the PFS by regulation.
9 of 9 payer prior-auth lists that name Q0484 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Gold-card eligible | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Gold-card eligible | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Oct 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| UnitedHealthcare Community Plan | Indiana Hoosier Care Connect | IN | prior auth under conditions | Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Indiana PathWays for Aging (MLTSS) | IN | prior auth under conditions | Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth under conditions | Prior authorization is required only for a retail purchase or cumulative rental cost of more than $1,000. | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
Q0484 appears in 5 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Centene, Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Ventricular Assist Devices (0654) | covered if criteria are met | Sep 10, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Total Artificial Hearts And Implantable Ventricular Assist Devices | covered if criteria are met | payer document | |
| BlueCross BlueShield of South Carolina | Total Artificial Hearts and Implantable Ventricular Assist Devices (CAM 70311) 33991 | ; both arterial and venous access, with transseptal puncture | listed, no stance (range Q0478-Q0509) | Mar 1, 2026 | payer document |
| Centene | Ventricular Assist Devices (CP.MP.46) | covered if criteria are met | Nov 1, 2025 | payer document |
| Regence | Ventricular Assist Devices and Total Artificial Hearts (Surgery 52) | listed, no stance (range Q0477-Q0509) | Jan 1, 2026 | payer document |
Prior authorization required or conditional in IL, IN, OH, WA.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.