Coverage Criteria for Nonwearable Automatic DefibrillatorsApril 19th, 2018 - Find-A-Code
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
- The beneficiary has one of the following conditions (1-8):
- A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause
- A sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia, either spontaneous or induced during an electrophysiologic (EP) study, not associated with acute myocardial infarction, and not due to a transient or reversible cause
- Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy
- Coronary artery disease with a documented prior myocardial infarction with a measured left ventricular ejection fraction less than or equal to 0.35, and inducible, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during an EP study. To meet this criterion;
- The myocardial infarction must have occurred more than 4 weeks prior to the external defibrillator prescription; and,
- The EP test must have been performed more than 4 weeks after the qualifying myocardial infarction.
- Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Beneficiaries must not have:
- Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; or,
- Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; or,
- Had an enzyme-positive MI within past month; or,
- Clinical symptoms or findings that would make them a candidate for coronary revascularization; or,
- Irreversible brain damage from preexisting cerebral disease; or,
- Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than one year.
- Beneficiaries with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI), New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) ≤ 35%.
- Beneficiaries with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%
- Beneficiaries who meet criteria (1-7) and have NYHA Class IV heart failure
- Implantation surgery is contraindicated
- A previously implanted defibrillator now requires explantation
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