Implantable Cardioverter-Defibrillators (ICDs) - Medical Necessity Criteria
Criteria for documenting medical necessity of implantable cardioverter-defibrillators (ICDs)
Contents:
- What is an implantable cardioverter-defibrillator?
- Are ICDs covered by insurance?
- When is an implantable cardioverter-defibrillator (ICD) medically necessary?
- Medical necessity criteria for implantable cardioverter-defibrillator (ICD)
- Does Medicare pay for implantable cardioverter-defibrillators?
- Health plan criteria for implantable cardioverter-defibrillator (ICD) and other references
What is an implantable cardioverter-defibrillator?
An implantable cardioverter-defibrillator (ICD) — such as the one placed on footballer Christian Eriksen after he collapsed during a Denmark game in Euro 2020 — is a small battery-powered device that is placed inside a person’s chest to keep track of the rhythm of their heart. It can detect any rapid, life-threatening heartbeat and deliver the electric shock needed to restore the heart’s normal rhythm.
Are ICDs covered by insurance?
Implantable cardioverter-defibrillators (ICDs) are covered by insurance when they are medically necessary for the person in whom they are intended to be placed.
When is an implantable cardioverter-defibrillator (ICD) medically necessary?
Generally, ICDs may be considered medically necessary for persons who have had, or are at high risk of, life-threatening ventricular tachyarrhythmias such as ventricular tachycardia (VT) and ventricular fibrillation (VF). They may also be considered medically necessary for persons with ischemic or non-ischemic dilated cardiomyopathy when the appropriate criteria are met.
Medical necessity criteria for implantable cardioverter-defibrillator (ICD)
When does a person need an ICD?
An implantable cardioverter-defibrillator may be considered medically necessary for individuals who meet any of the following conditions. Specific medical necessity criteria for each condition may vary among different health insurance companies so it is advised to verify the criteria followed by the individual’s insurance.
- Survivors of cardiac arrest that was due to either ventricular fibrillation or hemodynamically unstable sustained ventricular tachycardia
- An evaluation must have been done to define the cause of the event and to rule out causes that are completely reversible
- Patients with structural heart disease who have spontaneous sustained ventricular tachycardia
- Patients with hemodynamically significant, clinically relevant sustained ventricular tachycardia who experience syncope of undetermined origin
- Patients with non-ischemic dilated cardiomyopathy who meet all of the following criteria:
- left ventricular ejection fraction (LVEF) less than or equal to 35%
- have been on at least 3 months of guideline-directed medical therapy (GDMT)
- New York Heart Association (NYHA) functional Class II or III heart failure
- Patients with ischemic cardiomyopathy due to a prior myocardial infarction who meet all of the following criteria:
- at least 40 days have passed since the myocardial infarction (MI)
- either:
- LVEF less than or equal to 30% AND in NYHA functional Class I heart failure after 3 months of GDMT
- LVEF less than or equal to 35% AND in NYHA functional Class II or III heart failure after 3 months of GDMT
- Patients with nonsustained ventricular tachycardia due to prior myocardial infarction who have both:
- LVEF less than 40%
- inducible VF or sustained VT at electrophysiological study
- Patients with long-QT syndrome who are receiving beta blockers and experiencing either syncope or ventricular tachycardia
- Patients with confirmed hypertrophic cardiomyopathy (HCM) who have at least one major risk factor for sudden cardiac death (SCD)
- Patients with congenital heart disease and symptomatic sustained ventricular tachycardia
- Patients with congenital heart disease who experience recurrent syncope of undetermined origin with either:
- ventricular dysfunction
- inducible ventricular arrhythmias at electrophysiological study
- Patients with a familial or inherited condition that has a high risk of life-threatening ventricular tachyarrhythmias, such as:
- Brugada Syndrome, when the patient either:
- has had syncope
- has documented or inducible VT
- Cardiac sarcoidosis
- Chagas disease
- Giant cell myocarditis
- Brugada Syndrome, when the patient either:
Implantable cardioverter-defibrillators (ICDs) are generally considered experimental, investigational, and/or not medically necessary for persons with left ventricular assist devices (LVADs).
Again, medical necessity criteria vary among different health plans. Please verify coverage and medical necessity criteria with the patient’s health insurance company.
Does Medicare pay for implantable cardioverter-defibrillators?
Medicare may cover an implantable cardioverter-defibrillator (ICD) when the patient has any of the following conditions and meets the medical necessity criteria for the use of an ICD in such a condition:
- sustained ventricular tachyarrhythmia
- cardiac arrest due to ventricular fibrillation
- prior myocardial infarction and LVEF ≤ 0.30
- severe ischemic dilated cardiomyopathy
- severe non-ischemic dilated cardiomyopathy
- documented familial or genetic disorders with a high risk of life-threatening tachyarrhythmias
Health plan criteria for implantable cardioverter-defibrillator (ICD) and other references
- Anthem Blue Cross Criteria for Cardioverter Defibrillators
- Aetna Criteria for Cardioverter-Defibrillators
- Blue Shield of California Criteria for Implantable Cardioverter Defibrillators
- Medicare National Coverage Determination for Implantable Automatic Defibrillators
- UnitedHealthcare West Policy on Cardiac Pacemakers and Defibrillators