The implantation of an automatic defibrillator is a covered service when medically necessary. To be considered medically necessary, a patient must have had a documented episode of life-threatening ventricular tachyarrhythmia or cardiac arrest not associated with myocardial infarction.

The wearable cardioverter-defibrillator is indicated for adult patients who are at risk for sudden cardiac arrest and are not candidates for or refuse an implantable cardiac defibrillator.

The implantation of an automatic defibrillator is a covered service for patients with any of the following:

1. A documented episode of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause (427.41, 427.42, 427.5, 427.9);
2. Ventricular tachyarrhythmia, either spontaneous or induced, not due to a transient or reversible cause (427.0, 427.1, 427.2, 427.9);
3. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy (425.1, 426.82);
4. A history of a heart attack with reduced ejection fractions <30%, and a QRS complex >120 (410.00-410.92, 412, 428.0-428.1, 428.20-428.43, 428.9, 429.3);
5. Symptomatic ischemic dilated cardiomyopathy with a history of myocardial infarction at least 40 days before AICD treatment and left ventricular ejection fraction of 35% or less (414.8);
6. Symptomatic nonischemic dilated cardiomyopathy for more than 9 months' duration and left ventricular ejection fraction of 35% or less (425.4).

The following diagnosis codes are also eligible: 996.01, 996.04, 996.61, 996.72

Services performed for indications other than those listed above are considered not medically necessary and, therefore, are not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Analysis of Cardioverter-Defibrillator
Analysis of cardioverter-defibrillator systems is required for long-term routine follow-up care. Cardioverter-defibrillator monitoring (including analysis, evaluation, and interrogation) is an eligible service.

Device evaluation includes review of programmed parameters, lead(s), battery, capture and sensing function, presence or absence of therapy for ventricular tachyarrhythmias and underlying heart rhythm. Often, various components, e.g., AV intervals, pacing voltage, and diagnostics are adjusted.

Codes 93282-93284 represent a programming device evaluation with physician review and analysis. This is an "in person" service.

Code 93287 represents a periprocedural analysis with physician review and analysis.

This is an "in person" service which involves adjustment of the cardioverter-defibrillator prior to surgery, procedure, or test and is normally performed before and after the procedure. It can be done by the same provider, in which case the code is reported twice, or by different providers where each reports the procedure code once.

Codes 93289 and 93292 represent an "in person" interrogation device evaluation which involves the retrieval of stored and measured information to determine the current programming and settings.

Codes 93295 and 93296 represent a "remote" interrogation device evaluation. These codes can be reported only once in 90 days. Charges billed more frequently within the 90-day period are not eligible for separate payment. Additional monitoring during the 90-day period is considered part of the global allowance. A participating, preferred, or network provider cannot bill the member for the denied service(s).

Implantable Cardiovascular Monitor (ICM)
An implantable cardiovascular monitor (ICM) is used to assist the doctor in the management of non-rhythm related cardiac conditions such as heart failure. An ICM can be used in addition to an implantable cardioverter-defibrillator (ICD). ICM data and the ICD heart rhythm data such as sensing, pacing, and tachycardiac detection therapy are separate and distince services.

ICM services should be reported under procedure codes 93290, 93297, or 93299, as appropriate. Codes 93297 and 93299 should be reported and reimbursed only once in a 30-day period. Additional monitoring during the 30-day period is considered part of the global allowance. A participating, preferred, or network provider cannot bill the patient separately for additional monitoring during the 30-day period.

Electrophysiologic assessment is a more complex evaluation of newly or chronically implanted cardioverter-defibrillators. This is a covered service when medically necessary and should be processed under codes 93640, 93641, or 93642.

Description

The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.