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.