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.