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Background Psychosocial evaluation of candidates for advanced heart failure (HF) therapies identifies risk factors for poor outcomes. The degree of psychosocial risk considered acceptable to proceed with advanced therapies varies between centers. We hypothesized that rates of patients declined for advanced therapies because of mental health disorders, substance abuse and inadequate social support would differ for urban versus rural candidates, as community resources to mitigate risk factors vary. Methods Medical records for 213 consecutive patients undergoing psychosocial evaluation for advanced HF therapies between May 2014 and October 2017 were reviewed. Patients were separated into rural or urban categories based on home zip codes and urban influence codes from the United States Department of Agriculture. Demographics, comorbidities and psychosocial characteristics were collected. Categorical variables were compared using Fisher's exact test and continuous variables using the Student's t-test. Results The overall population was 54 years old, 27% female, and 23.5% African American with prevalent comorbidities. Regional codes identified 62 patients as rural and 151 patients as urban. Demographics and prevalence of medical and psychosocial comorbidities were similar between the two cohorts. There were no significant differences in the frequency of cited medical or social barriers alone to advanced therapies between cohorts. The combination of medical and social barriers was more commonly cited as the reason for ineligibility for transplant in rural patients (p=0.04). Conclusion Rural patients are more often declined for transplant due to combinations of medical and psychosocial concerns, despite similar prevalence of individual stressors. Further study is required to describe the differences in resources available to heart failure patients, standardize criteria among centers, and improve disparities in access to advanced therapies.