Does I42.0 require prior authorization?

No, I42.0 does not require prior authorization (high confidence). Covered without prior authorization.

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`I42.0`, Dilated cardiomyopathy

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For prior-MI and cardiomyopathy primary prevention indications, document LVEF value and measurement method (echocardiography, radionuclide imaging, cardiac MRI, or catheter angiography).
For indications B2–B5, document a formal shared decision‑making encounter using an evidence‑based decision tool between the patient and a physician or qualified non‑physician practitioner prior to initial ICD implantation.
Document clinical stability (eg, not in shock) at time of implantation and absence of significant irreversible brain damage or non‑cardiac disease with life expectancy <1 year.
When billing, include the applicable ICD-10-CM diagnosis codes listed in the NCD for the covered indication and for replacements include device/lead malfunction or ERI codes when applicable.

Key Coverage Criteria

Personal history of sustained ventricular tachycardia (spontaneous or EP-induced) not associated with an acute myocardial infarction and not due to a transient or reversible cause is an indication for ICD implantation.
Personal history of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause is an indication for ICD implantation.
Patients with prior myocardial infarction and measured left ventricular ejection fraction (LVEF) ≤ 0.30 are indicated for ICD implantation provided they do not have NYHA class IV heart failure, have not had CABG/PCI in the past 3 months, have not had an MI within the past 40 days, and are not candidates for coronary revascularization.
Patients with severe ischemic dilated cardiomyopathy, no prior sustained VT or VF arrest, NYHA class II or III heart failure, and LVEF ≤ 35% are indicated for ICD implantation provided they have not had CABG/PCI within 3 months, have not had MI within 40 days, and are not candidates for coronary revascularization.
Patients with severe non-ischemic dilated cardiomyopathy, no prior sustained VT or VF arrest, NYHA class II or III heart failure, LVEF ≤ 35%, and who have been on optimal medical therapy for at least 3 months are indicated for ICD implantation provided they have not had CABG/PCI within 3 months, have not had MI within 40 days, and are not candidates for coronary revascularization.
Patients with documented familial or genetic disorders conferring high risk of life‑threatening tachyarrhythmias (eg, long QT syndrome, hypertrophic cardiomyopathy) are indicated for ICD implantation.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L36139, MolDX: Biomarkers in Cardiovascular Risk Assessment

J15

CGS-J15-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J15-L33943, B-type Natriuretic Peptide (BNP) Testing

J15

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I42.0, Dilated cardiomyopathy