The implantation of an automatic defibrillator (33246, G0297, G0298 or 33249, G0299, G0300) 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 or wearing 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);
2. Ventricular tachyarrhythmia, either spontaneous or induced, not due to a transient or reversible cause (427.0, 427.1, 427.2);
3. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy (425.1, 794.30, 794.31);
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 (427.1, 427.41, 427.9);
6. Symptomatic nonischemic dilated cardiomyopathy for more than 9 months' duration and left ventricular ejection fraction of 35% or less (427.1, 427.41, 427.9).

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.

Electronic analysis of defibrillator systems is required for long-term routine follow-up care of implantable and wearable cardioverter-defibrillators. Automatic defibrillator monitoring is an eligible service and should be processed under codes 93741-93744, as appropriate.

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.

Coverage for the defibrillator device (L8499)(where the replacement is implanted in the physician’s office) or for the wearable device (K0606) is determined according to individual or group customer benefits.

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.

The wearable automatic cardioverter defibrillator is worn as a vest outside the body rather than implanted in the chest. The device continuously monitors two channels of ECG information, storing pertinent data for later review by the treating physician. The device is programmed to deliver a shock protocol in the event of a life-threatening arrhythmia. Prior to delivery of a shock, the device issues several alerts, providing an opportunity for the patient to manually abort the shock sequence in the event that the patient is conscious and not experiencing a life-threatening rhythm. If the patient is unconscious and the device detects a shockable rhythm, a life-saving shock is delivered even when no other human being is available to provide assistance. The monitor is capable of delivering up to five shocks based on redetection of the arrhythmia within a one-minute period of time.

The patient's physician must program the device (code 93745) tailored to the individual patient's medical history, defining the threshold for duration of occurrence and threshold rate of ventricular tachycardia required to trigger the shock protocol for that individual patient.

The device (K0606) records the patient's ECG information surrounding treatment events, allowing playback of arrhythmic events for physician review. An additional function allows the patient to download ECG data upon demand and transmit, via modem, for physician review and interpretation.

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.

PRN References

04/2003, Automatic implantable cardioverter-defibrillator coverage defined
02/2006, Blue Shield covers additional indications for the automatic implantable cardioverter-defibrillator