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Cardiac Resynchronization Therapy

An overview of market access challenges for cardiac resynchronization therapy in European countries.

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Procedure coding

Procedure coding is well-established for cardiac resynchronization therapy (CRT) in European countries. The implantation, replacement, and removal of the device for CRT are typically coded separately. Procedure codes for CRT implantation differ depending on its type: cardiac resynchronization therapy pacemaker (CRT-P) or cardiac resynchronization therapy defibrillator (CRT-D). 

For example, in Germany, there are specific OPS codes for implantation of the CRT-P (code 5-377.4 “Pacemaker, biventricular stimulation [three-chamber system]”) and implantation of CRT-D (code 5-377.7 “Defibrillator with biventricular stimulation”). The codes differ depending on the availability of the atrial electrode.

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Payment mechanism

The payment model for CRT implantation or replacement is DRG in most European countries.

In most countries, the DRG allocation depends on the CRT type with higher DRG tariffs for CRT-D. For example, in the Netherlands, implantation of the CRT-P system is reimbursed via DRG 099899030 “Surgical placement of a pacemaker that improves the pumping function of both the left and right ventricles during hospitalization, cardiology for a cardiac arrhythmia” with 2024 average cost of €16,485. In contrast, implantation of a CRT-D system is allocated to the DRG 979001242 “Implantation of ICD (defibrillator for two heart chambers), including insertion of electrodes for heart disease/lung disease” with a higher 2024 average cost of €23,590.

In most European countries, CRT systems do not attract additional (top-up) reimbursement, which is paid in addition to the DRG tariff. One exception is England, where there are specific add-on categories “ICD with CRT (Cardiac Resynchronisation Therapy) capability” and “Wireless CRT (Cardiac Resynchronisation Therapy) system” in the High Cost Devices List.

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Policy considerations

Due to the innovative origin and high cost, CRT can be subject to specific policies from payers or national decision-makers in the countries where such frameworks exist. 

For example, in England, the national payer, NHS England, developed so-called Service Specifications for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy, in which NHS England outlined patient pathways, eligible hospitals, responsibilities of different stakeholders, etc. The policy recommends CRT in patients with symptomatic heart failure on optimal drug therapy, severely impaired left ventricular function, and left ventricular dyssynchrony (through left bundle branch block or single site right ventricular (RV) pacing) manifest as a QRS wider than 120 ms.

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Health technology assessment

Due to the high cost and high clinical risks for patients and the existence of different clinical indications, CRT is often the subject of HTA in different European countries. 

For example, in Italy, the National Agency for Regional Health Services (AGENAS) published the rapid HTA report, in which evidence of CRT-D's effectiveness, safety, and cost-effectiveness was compared with ICD and CRT-P in patients with heart failure. The impact of CRT on heart failure depends on appropriate patient selection. No definite conclusion on the cost-effectiveness of CRT-D in comparison to CRT-P could be drawn due to the contradictory study results. However, the post-procedural costs of CRT-D were lower than those for ICD alone, and cost savings could increase in the long term.

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Future challenges

Standard CRT has established reimbursement and funding in most European countries. New health technology assessments are likely to be relevant for CRT systems with novel stimulation approaches (e.g., stimulation of the conduction system, wireless stimulation, etc.). Novel CRT systems can benefit from innovative payment schemes. 

Novel CRT systems with unique designs or alternative stimulation modes might need to develop specific procedure codes and adjust payment mechanisms to leverage their unique technology or cost profile fully. 

MTRC has experience with more than 6 projects related to cardiac resynchronization therapy in Europe

News and insights

Updates of the Belgian List of reimbursable devices in June 2025

In June 2025, Belgian INAMI/RIZIV updated the List of implants and invasive medical devices. Four new reimbursement codes were added to the List in relation to heart valve replacement. Several Nominative lists of brands were updated as well in the fields of neuromodulation, neurovascular, orthopedic, and cardiovascular.

The revised EBM catalog for the third quarter of 2025 published in Germany

On July 1, 2025, the revised EBM (German Uniform Evaluation Standard) catalog for the third quarter of 2025 came into force. The main changes introduced concern updates of the contents (services legends, preambles of several EBM subchapters) and the introduction of new EBM codes for the reimbursement of transmitters for telemonitoring and telemedical monitoring of implantable cardiac devices, as well as codes for the services provided within the co-funded study on low-dose pulsed ultrasound for pseudarthrosis.

The first release of the DRG package for 2026 was published in the Netherlands

On May 01, 2025, the Dutch Healthcare Authority (NZa) published the first release of the 2026 DRG package (RZ26a). Three new procedure codes, seven new supplementary payments (OZPs), one new diagnosis code, and two new DRGs will be implemented across in-vitro diagnostics, obstetrics and gynecology, neurology and neurosurgery, cardiovascular and other technology groups.

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