NCA - Implantable Cardioverter Defibrillators (CAG-00157R4)

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Surgical procedures covered when deemed medically necessary by a licensed physician. Coverage for outpatient procedures where the patient meets criteria for safe discharge. Covered when the service meets Medicare's definition of medical necessity. Applicable for patients with specified diagnoses as outlined in coverage criteria. Used for primary and secondary prevention of sudden cardiac death in patients with structural heart disease. Indicated for patients with history of ventricular arrhythmias or those at high risk. Coverage is provided for specific health services that are deemed medically necessary based on established criteria. The use of implantable cardioverter defibrillators (ICDs) is reasonable and necessary for the treatment of illness or injury. ICDs are also indicated to improve the functioning of a malformed body member. Cardiac MRI is covered to evaluate left ventricular ejection fraction (LVEF). Patients with severe non-ischemic dilated cardiomyopathy must be on optimal medical therapy (OMT) for at least 3 months prior to treatment consideration. Patients with a personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation. Patients with a prior myocardial infarction and a measured left ventricular ejection fraction (LVEF) ≤ 0.30.

Not covered for procedures deemed elective or not medically necessary. Coverage limited to patients aged 18 and older. Not covered for services rendered without prior authorization. Limited to specific patient age groups as described in the policy. Not covered for patients without a prior history of cardiac arrest or lethal arrhythmia. Will not cover for patients with reversible causes of arrhythmia. Services not deemed medically necessary will not be covered. Certain frequency limits apply based on the type of service provided. Class IV heart failure requirement for cardiac resynchronization therapy (CRT) has been removed. Patients must have a patient shared decision making (SDM) interaction prior to ICD implantation. Patients must not have New York Heart Association (NYHA) classification IV heart failure. Patients must not have had a coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) with angioplasty and/or stenting.

Pre-operative clinical notes detailing necessity for surgery. Post-operative documentation supporting complications or outcomes. Clinical documentation supporting the medical necessity of the service. Prior authorization documentation must be included when applicable. Clinical notes must document the indication for ICD placement. Prior authorization is required before implantation. Clinical notes supporting medical necessity are required. Prior authorization documentation must be submitted for review. Patient must show evidence of optimal medical therapy (OMT) duration. Documentation of shared decision making (SDM) interaction is required.