2.1 A wearable
AED (HCPCS code K0606) may be covered when at least one of the following
are documented.
2.1.1 An
episode of ventricular fibrillation or a sustained, lasting 30 seconds
or longer, ventricular tachyarrhythmia (NOT occurring during the
first 48 hours after an acute Myocardial Infarction (MI));
2.1.2 A familial
or inherited condition with a high risk of life-threatening ventricular tachyarrhythmia,
such as long QT syndrome or hypertrophic cardiomyopathy;
2.1.3 Either
a prior MI or dilated cardiomyopathy with a measured left ventricular
ejection fraction less than or equal to 0.35; or
2.1.4 A previously
implanted defibrillator requires explantation.
2.2 A non-wearable
AED (HCPCS code E0617) may be covered when a previously implanted defibrillator
requires explantation OR when an implanted AED is contraindicated
AND one of the following is documented.
2.2.1 An episode of cardiac arrest
due to ventricular fibrillation, not due to a transient or reversible
cause;
2.2.2 An episode of ventricular fibrillation or a
sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia
not associated with acute MI and not due to a transient or reversible
cause;
2.2.3 A familial or inherited condition with a high
risk of life-threatening ventricular tachyarrhythmia, such as long
QT syndrome or hypertrophic cardiomyopathy;
2.2.4 Coronary
artery disease with a prior MI with a measured left ventricular
ejection fraction less than or equal to 0.35 and inducible, sustained
ventricular tachycardia or ventricular fibrillation during an electrophysiologic
(EP) study. To meet this criterion:
• The MI must have occurred
more than four weeks prior to prescribing the external defibrillator;
and
• The
EP test must have been performed more than four weeks after the
qualifying MI.
2.2.5 A prior MI and measured left
ventricular ejection fraction less than or equal to 0.30, but only when
the beneficiary:
• Does not have cardiogenic
shock or symptomatic hypotension while in a stable baseline rhythm;
• Has not had a coronary
artery bypass graft or percutaneous transluminal coronary angioplasty
within the past three months;
• Has not had an enzyme-positive
MI within the past month;
• Does not have clinical
symptoms or findings that would make them a candidate for coronary
revascularization;
• Does
not have irreversible brain damage from preexisting cerebral disease;
or
• Does
not have any disease, other than cardiac disease (e.g., cancer,
uremia, liver failure), associated with a likelihood of survival
less than one year.
2.2.6 Has ischemic dilated cardiomyopathy,
documented prior MI, New York Heart Association (NYHA) Class II
and III heart failure, and measured left ventricular ejection fraction
less than or equal to 35%;
2.2.7 Has
non-ischemic dilated cardiomyopathy greater than three months, NYHA
Class II and III heart failure, and measured left ventricular ejection
fraction less than or equal to 35%; or
2.2.8 Meets one of the previous
criteria (
paragraphs 2.1.1 through
2.2.7)
AND has NYHA Class IV heart failure.