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CPT codes, descriptions and other data only are copyright 2006
American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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For any item to be covered by Medicare, it must 1) be eligible
for a defined Medicare benefit category, 2) be reasonable and necessary for
the diagnosis or treatment of illness or injury or to improve the functioning
of a malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
medical policy, the criteria for "reasonable and necessary" are
defined by the following indications and limitations of coverage and/or
medical necessity.
For an item to be covered by Medicare a written signed and dated order must
be received by the supplier before a claim is submitted. If the supplier
bills for an item addressed in this policy without first receiving the
completed order, the item will be denied as not medically necessary.
Automatic external defibrillators are covered for patients at high risk for
sudden cardiac death (SCD) due to one of the conditions described under I
or II. It is expected the ordering physician be experienced in the
management of patients at risk for SCD.
- A wearable defibrillator
(K0606) is covered for patients if they meet one of the criteria
(1-4), described below: .
- A
documented episode of ventricular fibrillation or a sustained,
lasting 30 seconds or longer, ventricular tachyarrhythmia. These
dysrhythmias may be either spontaneous or induced during an
electrophysiologic (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 (ICD-9 427.1, 427.42, 427.5); or
- Familial
or inherited conditions with a high risk of life-threatening
ventricular tachyarrhythmia such as long QT syndrome (ICD-9 426.82)
or hypertrophic cardiomyopathy (ICD-9 425.1); or
- Either
documented prior myocardial infarction (ICD-9 410.00-410.92, 412) or
dilated cardiomyopathy (ICD-9 425.0-425.9) and a measured left
ventricular ejection fraction less than or equal to 0.35; or
- A
previously implanted defibrillator now requires explantation (ICD-9
996.04, 996.61)
- A nonwearable automatic
defibrillator (E0617) is covered for patients in two circumstances.
They meet either (1) both criteria A and B or (2) criteria C,
described below
A.
The patient 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 (ICD-9
427.41, 427.42, 427.5).
- 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 (ICD-9
427.1).
- Familial
or inherited conditions with a high risk of life-threatening
ventricular tachyarrythmias such as long QT syndrome (ICD-9 426.82)
or hypertrophic cardiomyopathy (ICD-9 425.1).
- Coronary
artery disease with a documented prior myocardial infarction, (ICD-9
410.00 – 410.92, 412) 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 (ICD-9 410.00-410.92, 412) and a
measured left ventricular ejection fraction less than or equal to
0.30. Patients 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.
- Patients
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%.
- Patients
with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class
II and III heart failure, and measured LVEF ≤ 35%.
- Patients
who meet one of the previous criteria (1-7) and have NYHA Class IV
heart failure.
B.
Implantation surgery is contraindicated.
C.
A previously implanted defibrillator now requires explantation
(ICD-9 996.04, 996.61).
Claims for defibrillators for other indications will be denied as not
medically necessary.
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