Abstract
Cardiac implantable electronic devices (CIEDs), despite their proven effectiveness in large clinical trials for a wide range of patients with arrhythmia and heart failure, are frequent targets for criticism regarding cost-efficiency and alleged overuse. Newer indications, such as sinus node dysfunction for pacemakers and primary prevention for implantable cardioverter-defibrillators, increased eligible patient population significantly. This lead to heightened scrutiny from payors and legislative agencies, such as prior authorization and mandatory registry participation. Despite the significant administrative burden, the efficiency of these measures to decrease abuse is not clear. In addition, professional societies, regulatory agencies, and payors may not always agree whether use of a device is appropriate for a given patient. The review focuses on past and current issues related to utilization of CIEDs, which lead to increased regulatory oversight, and the effort of professional societies, payors, and governmental agencies to improve access to these life-saving therapeutical modalities while maintaining a just and cost-efficient healthcare system.