Effective Date:                                                      

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cardioverter-defibrillators, whether implantable or wearable (external) require pre-authorization.

2)    Either implanted or wearable, defibrillators are used in patients with unstable heart conditions who need protection from abnormal, fatal heart arrhythmias.

3)    Defibrillators are covered under the medical benefit.

4)    External defibrillator with integrated electrocardiogram analysis is not covered and is considered experimental and investigational.

Transvenous Implantable Cardioverter-Defibrillators

A. FDA-approved implantable Transvenous cardioverter-defibrillators (thoracotomy and non-thoracotomy systems) or subcutaneous implantable cardioverter-defibrillators require pre-authorization and are considered medically necessary for the following indications:

1. Members after one or more episodes of spontaneously occurring or  inducible ventricular fibrillation (VF) or syncopal or hypotensive ventricular tachycardia (VT) that is not associated with acute myocardial infarction; not due to a remediable cause (e.g., drug toxicity, electrolyte abnormalities, ischemia); and neither controlled by appropriate drug therapy after serial testing nor amenable to definitive therapy (e.g., surgical ablation); or
2. Members after spontaneously occurring but non-inducible documented syncopal or hypotensive VT that was not due to acute myocardial infarction; not controlled by appropriate drug therapy after serial testing; nor amenable to definitive therapy (e.g., surgical ablation); or
3. Members after VT/VF cardiac arrest that was not associated with an inducible ventricular arrhythmia, and not due to acute myocardial infarction; not controlled by appropriate drug therapy after serial testing; nor amenable to definitive therapy (e.g., surgical ablation); or
4. Members after surgery for VT or VF if the ventricular arrhythmia remains inducible; or
5. Members after one or more episodes of spontaneously occurring and inducible VF or syncopal or hypotensive VT that is associated with acute myocardial infarction (greater than 2 days after the infarct but less than 1 month); not due to a remediable cause; and neither controlled by appropriate drug therapy after multiple trials nor amenable to definitive therapy; or
6. Members after unexplained syncope, which by history and clinical circumstances was probably due to a ventricular tachyarrhythmia, and in the presence of reproducible inducible syncopal or hypotensive VT or VF that is not associated with acute myocardial infarction (greater than 2 days after the infarct but less than 1 month); not due to a remediable cause; and neither controlled by appropriate drug therapy after multiple trials nor amenable to definitive therapy; or
7. Members after VF or syncopal or hypotensive VT that is apparently controlled by drug, surgical, or ablative therapy, but in which the results of treatment are too unpredictable (e.g., when long-term effectiveness is in doubt or unknown; in the presence of side effects or toxicity leading to non-compliance; left ventricular (LV) ejection fraction less than or equal to 30% despite drug control) to justify withholding implantable cardioverter-defibrillator treatment; or
8. Members with familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia’s such as long QT syndrome or hypertrophic cardiomyopathy; or
9. Members with ischemic dilated cardiomyopathy with a LV ejection fraction less than or equal to 35% and New York Heart Association (NYHA) Class II or III heart failure (see appendix) who have a history of heart attack; or
10. Members with non-ischemic dilated cardiomyopathy greater than 3 months duration, NYHA Class II or III heart failure (see appendix), and a LV ejection fraction less than or equal to 35% been on optimal medical therapy (OMT) for at least 3 months.  Additionally, patients must not have:

a)    Had a coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) with angioplasty and/or stenting, within the past 3 months; or

b)    Had a myocardial infarction within the past 40 days; or c) Clinical symptoms and findings that would make them a candidate for coronary revascularization.

B.   For each of these groups listed above, the following additional criteria must also be met:

1. Patients must be clinically stable (e.g., not in shock, from any etiology);
2. Left ventricular ejection fraction (LVEF) must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac magnetic resonance imaging (MRI), or catheter angiography;
3. Patients must not have:
   • Significant, irreversible brain damage; or
   • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than 1 year; or
   • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.

 Wearable Cardioverter-Defibrillators (Requires Pre-authorization)

Wearable cardioverter-defibrillators (WCDs, Life Vest) (automatic external cardioverter-defibrillators that are worn under the member`s clothing) are considered medically necessary durable medical equipment (DME) only for members who meet any of the following criteria:  

• A documented episode of VF or a sustained, lasting 30 seconds or longer, VT (these dysrhythmias may be either spontaneous or induced during an electro physiologic (EP) study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute myocardial infarction); or
• Familial or inherited conditions with a high risk of life-threatening VT such as long QT syndrome or hypertrophic cardiomyopathy; or
• Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 35%; or
• A previously implanted defibrillator now requires replacement.

For members with a new diagnosis of heart failure, where there is a likelihood that ejection fraction improvement will occur, approval will be for 90 days.  Otherwise, the maximum approval period is for 60 consecutive days. Additional days require Medical Director’s approval. Additional days will typically be authorized only for:

i)     A diagnosis of cardiomyopathy with the expectation of recovery, AND there is demonstrated improvement in heart failure symptoms and ejection fraction; OR

ii)    A documented episode of VF or VT in a patient whose condition is not yet controlled with drug therapy, but where additional drug therapy is reasonably expected to obviate the need for automated defibrillation.

iii)   In all other cases, it is expected that arrangements for definitive treatment (e.g., ablation, AICD placement) will be made within 60 days.

Codes Used In This BI:

Implantable cardioverter-defibrillators are not considered medically necessary in any of the following situations:

1. When other disease processes are present that clearly and severely limit the member`s life expectancy; or
2. Member has asymptomatic VT or symptomatic VT/VF that is (i) associated with acute myocardial infarction within 2 days, (ii) due to a remediable cause, (iii) controlled by appropriate drug therapy, and (iv) amenable to definitive therapy (e.g., ablative procedures, surgery); or
3. Prophylactic use in members at high risk for sudden cardiac death (e.g., persons with mutations of desmoglein 2) who have not experienced a life threatening arrhythmia (other than members meeting criterion 9 or 10 above); or
4. Use as a “bridge” to heart transplant.

1.     Center for Medicare and Medicaid Services (CMS). Decision Memo for Implantable Defibrillators (CAG-00157R3). Medicare Coverage Database. Baltimore, MD: CMS; January 27, 2005. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=148.

2.     Bardy GH, Lee KL, Mark DB, et al., and the SCD-HeFT Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005; 352:225-237.

3.     Goldman L, Hashimoto B, Cook EF, et al. Comparative reproducibility, and validity of systems for assessing cardiovascular functional class: Advantages of a new specific activity scale. Circulation. 1981; 64(6):1227-1264.

4.     Lee DS, Green LD, Liu PP, et al. Effectiveness of implantable defibrillators for preventing arrhythmic events and death: A meta-analysis. J Am Coll Cardiol. 2003; 41(9):1573-1582.

5.     Lee DSY, Green LD, Liu PP, et al. Implantable defibrillators vs antiarrhythmic drugs for left ventricular dysfunction. Cochrane Database Systematic Rev. 2002; 2:CD003613.

6.     Bryant J, Brodin H, Loveman E, et al. The clinical and cost-effectiveness of implantable cardioverter defibrillators: A systematic review. Health Technol Assess. 2005; 9(36):1-150.

7.     Ontario Ministry of Health and Long-Term Care, Medical Advisory Secretariat (MAS). Implantable cardioverter defibrillator: Prophylactic Use. Health Technology Literature Review: 2005 Update of 2003 Review. Toronto, ON: MAS; September 2005.

8.     Traub D, Ganz L. Implantable cardioverter-defibrillators for secondary prevention: Is it worth it in the elderly? Am J Geriatr Cardiol. 2006; 15(2):93-99.

9.     Franz WM, Müller OJ, Katus HA. Cardiomyopathies: From genetics to the prospect of treatment. Lancet. 2001; 358(9293):1627-1637.

10. Pilichou K, Nava A, Basso C, et al. Mutations in desmoglein-2 gene are associated with arrhythmogenic right ventricular cardiomyopathy. Circulation. 2006; 113(9):1171-1179.

11. Makikallio TH, Huikuri HV. Association between usage of beta-blocking medication and benefit from implantable cardioverter therapy. Am J Cardiol. 2006; 98(9):1245-1247.

12. Buxton M, Caine N, Chase D, et al. A review of the evidence on the effects and costs of implantable cardioverter defibrillator therapy in different patient groups, and modelling of cost-effectiveness and cost-utility for these groups in a UK context. Health Technol Assess. 2006; 10(27):1-180.

13. Alcaraz A, Augustovski F, Pichon-Riviere A. Implantable cardioverter defibrillators [summary]. Report ITB No. 25. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); 2006.

14. National Institute for Health and Clinical Excellence (NICE). Implantable cardioverter defibrillators for arrhythmias: Review of Technology Appraisal 11. Technology Appraisal 95. London, UK: NICE; 2006.

15. Medical Services Advisory Committee (MSAC). Implantable cardioverter defibrillators for prevention of sudden cardiac death. MSAC Reference 32. Canberra, ACT: MSAC; 2006.

16. Sharieff W, Kaulback K. Assessing automated external defibrillators in preventing deaths from sudden cardiac arrest: An economic evaluation. Int J Technol Assess Health Care. 2007; 23(3):362-367.

17. McAlister FA, Ezekowitz J, Dryden DM, et al. Cardiac resynchronization therapy, and implantable cardiac defibrillators in left ventricular systolic dysfunction. Prepared by the University of Alberta Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). AHRQ Publication No. 07-E009. Rockville, MD: AHRQ; June 2007.

18. Van Brabandt H, Thiry N, Neyt M, et al. The implantable cardioverter defibrillator: A health technology assessment. KCE Reports 58C. Brussels, Belgium: Belgian Health Care Knowledge Center (KCE); 2007.

19. Blom NA. Implantable cardioverter-defibrillators in children. Pacing Clin Electrophysiology. 2008; 31 Suppl 1:S32-S34.

20. Bardy GH, Lee KL, Mark DB, et al; HAT Investigators. Home use of automated external defibrillators for sudden cardiac arrest. N Engl J Med. 2008; 358(17):1793-1804.

21. TriCenturion, LLC. Automatic external defibrillators. Local Coverage Determination No. L13613. Durable Medical Equipment Program Safeguard Contractor (DME PSC). Columbia, SC: TriCenturion; revised July 1, 2007.

22. Gula LJ, Massel D, Krahn AD, et al. Is defibrillation testing still necessary? A decision analysis and Markov model. J Cardiovascular Electrophysiology. 2008; 19(4):400-405.

23. Liu QM, Bai ZL, Liu ZJ, et al. Defibrillation threshold testing: Is it necessary during implantable cardioverter-defibrillator implantation? Med Hypotheses. 2009; 72(2):147-149.

24. Das M. Indications for ICD and cardiac resynchronization therapy for prevention of sudden cardiac death. Expert Rev Cardiovascular Ther. 2009; 7(2):181-195.

25. Exner DV. Implantable cardioverter defibrillator therapy for patients with less severe left ventricular dysfunction. Curr Opin Cardiol. 2009; 24(1):61-67.

26. ClinicalTrials.gov. A prospective, randomized comparison of subcutaneous and transvenous implantable cardioverter defibrillator therapy (PRAETORIAN).  NCT01296022.  Accessed 17 July 2014

Addendum:

1.     Effective 07/01/2017: Removed the following CPT codes from the BI: 0319T – 0325T. These codes were deleted 1/1/15 and replaced with 33240 – 33241, 33262 – 33264, and 33270 – 33273.

2.     Effective 12/01/2017: Clarified PA requirements to prevent confusion.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.