Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 04/07/2010 Title: Cardioverter-Defibrillators
Revision Date: 06/01/2018 Document: BI265:00
CPT Code(s): C1721, C1722, C1777, C1882, C1895, C1896, C1899, E0617, K0606-K0609, 33240, 33241, 33249, 33262-33264, 33270-33273
Public Statement

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.


Medical Statement

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:

C1721

Implantable cardioverter-defibrillator, dual chamber

C1722

Implantable cardioverter-defibrillator, sngl chamber

C1777

Implantable lead cardioverter-defibrillator, endocardial sngl coil

C1882

Implantable cardioverter-defibrillator, other than sngl or dual chamber

C1895

Implantable lead cardioverter-defibrillator, endocardial dual coil

C1896

Implantable lead cardioverter-defibrillator, other than endocardial sngl or dual coil

C1899

Implantable lead pacemaker/cardioverter-defibrillator combination

E0617

Extrnl defibrillator w/integrated ECG analysis

K0606

Auto extrnl defibrillator w/integrated ECG analysis, garment type

K0607

Replcmnt battery for auto extrnl defibrillator, garment type only, ea

K0608

Replcmnt garment for use w/auto extrnl defibrillator, ea

K0609

Replcmnt electrodes for use w/auto extrnl defibrillator, garment type only, ea

33240

Insrtn of implantable defibrillator pulse generator only; w/existing sngl lead

33241

Remvl of implantable defibrillator pulse generator only

33249

Insrtn or replcmnt of permnt implantable defibrillator syst

33262

Remvl & replcmnt of implantable defibrillator pulse generator; sngl lead syst

33263

Remvl & replcmnt of implantable defibrillator pulse generator; dual lead syst

33264

Remvl & replcmnt of implantable defibrillator pulse generator; mult lead syst

33270

Insrtn or replcmnt of permnt subcutaneous implantable defibrillator syst

33271

Insrtn of subcutaneous implantable defibrillator electrode

33272

Remvl of subcutaneous implantable defibrillator electrode

33273

Repositioning of prev implanted subcutaneous implantable defibrillator electrode


Limits

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.

Background

Available literature indicates implantable cardioverter-defibrillators (ICDs) are now widely used for the secondary prevention of sudden cardiac death due to VF or VT. Ventricular tachycardia or VF can be secondary to a variety of conditions: progression in underlying pathology (i.e., deterioration of left ventricular function or worsening of coronary artery disease), autonomic imbalance, electrolyte abnormalities, or even pharmacological intervention. The ICD is generally accepted as treatment for patients who have experienced an episode of VF not accompanied by an acute myocardial infarction or other transient or reversible causes (e.g., drug toxicity, electrolyte abnormalities, and ischemia). Additionally, accepted guidelines prefer this treatment in patients with sustained VT causing syncope or hemodynamic compromise. As primary prevention, the literature shows the ICD is superior to conventional anti-arrhythmic drug therapy in patients who have survived a myocardial infarction and who have spontaneous, non-sustained VT, a low ejection fraction, inducible VT at electrophysiological study, and whose VT is not suppressed by procainamide.

A number of well-designed studies have shown the effectiveness of the ICD in high-risk patients who have already experienced a myocardial infarction (MI). Schlapfer and colleagues (2002) compared the long-term survival rates of patients with sustained ventricular tachyarrhythmia after MI who were treated according to the results of EP study either with amiodarone or an ICD. They found that the long-term survival of patients with sustained ventricular tachyarrhythmia’s after MI, with depressed LV function, is significantly better with an ICD than with amiodarone therapy, even when stratified according to the results of the EP study. In a randomized controlled study (n = 1232) to evaluate the effect of an implantable defibrillator on survival of patients with reduced LV function after MI, Moss et al (2002) concluded that in patients with a prior MI and advanced LV dysfunction, prophylactic implantation of a defibrillator improves survival and should be considered as a recommended therapy.

CMS expanded coverage of implantable cardioverter defibrillators to persons with non-ischemic dilated cardiomyopathy, based primarily on the results of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), a prospective randomized trial to determine whether amiodarone or an implantable cardioverter-defibrillator will improve survival compared to placebo in patients with NYHA Class II and Class III heart failure and reduced left ventricular ejection fraction less than 35 percent. The study included persons with non-ischemic dilated cardiomyopathy and patients with ischemic dilated cardiomyopathy. A total of 2521 patients were enrolled, 847 of whom were assigned to placebo plus conventional heart failure therapy, 845 to amiodarone plus conventional heart failure therapy, and 829 to single lead ICD plus conventional heart failure therapy. There was a significant reduction in all-cause mortality in the ICD group compared to the placebo group (hazard ratio compared to control = 0.77; 97.5% confidence intervals 0.62 to 0.96, p = 0.007). For patients with ischemic dilated cardiomyopathy, there was a reduction in mortality hazard ratio compared to control but it was not statistically significant (hazard ratio 0.79; 97.5% confidence interval 0.60 to 1.04). For patients with non-ischemic dilated cardiomyopathy, there was a reduction in the mortality hazard ratio for ICD therapy compared to control but it was also not statistically significant (hazard ratio 0.73; 97.5% confidence interval 0.50-1.07). CMS noted that the absolute reduction in mortality was modest for a trial with a median follow-up of 45.5 months.

In 2012, a subcutaneous ICD system was approved by the FDA. This system does not employ transvenous leads, and so avoids the potential complications associated with venous access. The system is especially attractive in younger patients, who might have to undergo multiple procedures over time because of fatigue failure of the leads. 


Reference

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.


Application to Products

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.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.