93644
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.96
Facility
$189.05
Non-Facility
$189.05
Documentation Required
- Clinical documentation of the qualifying event or diagnosis (e.g., cardiac arrest, VF/VT, sustained VT) and that reversible causes have been excluded when required (e.g., ischemia, electrolyte disorder).
- Left ventricular ejection fraction (LVEF) measurements (echo/CMR) with date(s) to document eligibility thresholds (eg, ≤35%, ≤40%, >48 hours/40 days post-MI etc.).
- Timing documentation relative to myocardial infarction and revascularization (dates of MI, PCI, CABG) to confirm windows (eg, >48 hours and <40 days post-MI; <90 days post-revascularization; ≥90 days when applicable).
- Results of electrophysiological study (EPS) including inducible sustained VT/VF status when EPS-based indications are cited.
Key Coverage Criteria
- Transvenous ICD — Secondary prevention of sudden cardiac death for ANY of the following: cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable sustained ventricular tachycardia (VT) after reversible causes (e.g., myocardial ischemia, electrolyte disorder) have been excluded.
- Transvenous ICD — Secondary prevention: individual with structural heart disease (e.g., prior MI, cardiomyopathy, valvular heart disease, adult congenital heart disease) and spontaneous sustained VT, whether hemodynamically stable or unstable.
- Transvenous ICD — Secondary prevention: individual with genetic conditions associated with sustained VT/VF (congenital long QT, short QT, catecholaminergic polymorphic VT, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy).
- Transvenous ICD — Secondary prevention: individual without structural heart disease (LVEF > 50%) or known genetic causes of sustained VT/VF and EITHER bradycardia-dependent VT/VF OR idiopathic VF/VT with normal ventricular function.
- Transvenous ICD — Secondary prevention: individual with unexplained syncope due to ANY of the following: cardiac sarcoidosis with documented spontaneous sustained VT; ischemic heart disease with inducible sustained monomorphic VT on electrophysiological study; left ventricular non-compaction; nonischemic dilated cardiomyopathy with LVEF ≤ 49%; structural heart disease (e.g., prior MI) with LVEF ≤ 35%; structural heart disease with LVEF 36%-49% and inducible sustained VT/VF on EPS; tetralogy of F [...]
- Transvenous ICD — Secondary prevention: individual with syncope of suspected arrhythmic cause and ANY of the following: arrhythmogenic right ventricular cardiomyopathy (ARVC); Brugada ECG pattern; cardiac amyloidosis; catecholaminergic polymorphic VT (CPVT); hypertrophic cardiomyopathy (HCM); Long QT Syndrome (LQTS) with either syncope while receiving beta-blockers OR beta-blockers are contraindicated.
3 Active Policies
CARELON-electrophysiological-studies-2024-07-01 — Electrophysiological Studies
CIGNA-0431 — Cardioverter-Defibrillator Devices - (0431)
HUMANA-CARDIOVERTER-DEFIBRILLATORSCARDIAC-RESYNCHRONIZATION-THERAPY-MA — Cardioverter Defibrillators/Cardiac Resynchronization Therapy - Medicare Advantage
Related Codes
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