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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 5.4
Automated External Defibrillators (AEDs)
Issue Date:  February 26, 1986
Revision:  C-1, March 10, 2017
1.0  DESCRIPTION
An AED is a portable electronic device that is used to treat life threatening cardiac arrhythmias through the application of electrical therapy which stops the arrhythmia (defibrillation), allowing the heart to reestablish an effective rhythm. There are two major types of AEDs, wearable and non-wearable.
2.0  POLICY
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.
3.0  POLICY CONSIDERATIONS
3.1  A prescription for an AED from a TRICARE-authorized provider is required.
3.2  The AED must be provided by a TRICARE-authorized supplier.
3.3  Coverage may be extended for either a wearable or non-wearable AED when a beneficiary meets the coverage criteria for both. However, because wearable and non-wearable AEDs serve the same purpose only one type (wearable OR non-wearable) may be cost-shared. Please reference Section 2.1, paragraph 3.11, concerning duplicate equipment.
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