C1721, Cardioverter-defibrillator, dual chamber (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No documentation requirements, medical records, test results, or specific clinical documentation are specified in the provided text.
- No documentation requirements are specified in the provided text.
- Full documentation requirements (e.g., clinical notes, prior testing, ICD-10 diagnoses) may be provided elsewhere in the complete policy.
- Documentation that an implantable cardioverter-defibrillator (ICD) is contraindicated for the patient (when that is the basis for eligibility).
Key Coverage Criteria
- Sustained VT (spontaneous or induced during EPS) not associated with acute MI and not due to a transient or reversible cause ${ }^{6} ;$
- Documented MI with LVEF less than or equal to $30 \%{ }^{6}$;
- Automated external defibrillators (AEDs) are portable electronic devices that allow a minimally trained individual to provide electric shock to prevent death due to sudden cardiac arrest.
- These devices monitor heart rhythm and can, if needed, deliver an electric shock to the chest wall much like a traditional (paddle) defibrillator in a hospital.
- The implantable (transvenous) cardioverter defibrillator (ICD) continuously monitors the heart rhythm and delivers therapy in response to a ventricular tachyarrhythmia that meets preprogrammed detection rates and duration in an individual who is at high risk of sudden cardiac death (SCD).
- If the heart develops a sudden life-threatening fast rhythm, the device will either deliver rapid electrical pacing pulses to terminate the arrhythmia or deliver a shock to the inside of the heart to stop the abnormal rhythm.
6 Active Policies
HUMANA-CARDIAC-DEVICES-VA-MEDICAID, Cardiac Devices
BCBSIL-SUR707.003, Implantable Cardioverter Defibrillators
BCBSMT-SUR707.003, Implantable Cardioverter Defibrillators
BCBSNM-SUR707.003, Implantable Cardioverter Defibrillators
BCBSOK-SUR707.003, Implantable Cardioverter Defibrillators
Related Codes
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