33263
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.93
Facility
$342.36
Non-Facility
$342.36
Documentation Required
- For patients meeting B2–B5, a formal shared decision-making encounter using an evidence‑based decision tool must occur with a physician or qualified non‑physician practitioner prior to initial ICD implantation; this encounter may be a separate visit and must be documented.
- Left ventricular ejection fraction (LVEF) must be measured and documented by echocardiography, radionuclide (nuclear) imaging, cardiac MRI, or catheter angiography.
- Claims must include the specific ICD‑10‑CM diagnosis codes required for each indication (e.g., B2 requires I25.2 billed with one of I50.21/I50.22/I50.23/I50.41/I50.42/I50.43; B3 requires I25.5 with one of the I50 codes; B4 requires I42.x codes with one of the I50 codes; B1 and B5 require their listed arrhythmia/cardiomyopathy codes; replacements require T82.x or Z45.02 as applicable).
Key Coverage Criteria
- Patients with a personal history of sustained ventricular tachyarrhythmia (sustained VT) or cardiac arrest due to ventricular fibrillation (VF) not associated with an acute myocardial infarction and not due to a transient or reversible cause are covered for ICD implantation.
- Patients with prior myocardial infarction and measured left ventricular ejection fraction (LVEF) ≤ 0.30 are covered for ICD implantation provided they do not have NYHA class IV heart failure, have not had CABG or PCI within the past 3 months, have not had an MI within the past 40 days, and are not clinical candidates for coronary revascularization.
- Patients with severe ischemic dilated cardiomyopathy without a personal history of sustained VT or cardiac arrest, who have NYHA class II or III heart failure and LVEF ≤ 35% are covered for ICD implantation provided they have not had CABG/PCI within 3 months, have not had an MI within 40 days, and are not candidates for coronary revascularization.
- Patients with severe non-ischemic dilated cardiomyopathy without prior cardiac arrest or sustained VT who have NYHA class II or III heart failure, LVEF ≤ 35%, and have been on optimal medical therapy for at least 3 months are covered for ICD implantation provided they have not had CABG/PCI within 3 months, have not had an 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 (e.g., long QT syndrome, hypertrophic cardiomyopathy) are covered for ICD implantation.
- Patients with an existing ICD may receive a replacement ICD when required due to end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.
11 Active Policies
A56391 — Billing and Coding: Implantable Automatic Defibrillators
J05
A56326 — Billing and Coding: Implantable Automatic Defibrillators
J06
A56343 — Billing and Coding: Implantable Automatic Defibrillators
A57994 — Billing and Coding: Implantable Automatic Defibrillators
CARELON-cardiac-resynchronization-therapy-2024-10-20
Related Codes
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