C1896, Lead, cardioverter-defibrillator, other than endocardial single or dual coil
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical evaluation of LQTS risk factors for ICD consideration should be individualized and performed by a clinician with LQTS expertise.
- Document LVEF measurement by echocardiography, radionuclide imaging, cardiac MRI, or catheter angiography.
- Providers may be required to submit clinical documentation in support of a request for services. Such documentation must a) accurately reflect the clinical situation at the time of the requested service, and b) sufficiently document the ordering provider’s clinical intent.
Key Coverage Criteria
- ICD indicated for BrS patients who develop ventricular fibrillation during programmed electrical stimulation.
- ICD should be considered for secondary prevention in individuals with cardiac ion channelopathies who have had a life-threatening ventricular arrhythmic event (eg, sustained ventricular tachyarrhythmia) after reversible causes are addressed.
- ICD indicated for individuals with long QT syndrome (LQTS) who are survivors of cardiac arrest.
- ICD indicated for individuals with LQTS who have recurrent syncope despite β-blocker therapy.
- ICD indicated for individuals with Brugada syndrome (BrS) who are survivors of cardiac arrest.
- ICD indicated for BrS patients with documented spontaneous sustained VT, with or without syncope.
5 Active Policies
BCBSIL-SUR707.003, Implantable Cardioverter Defibrillators
BCBSMT-SUR707.003, Implantable Cardioverter Defibrillators
BCBSNM-SUR707.003, Implantable Cardioverter Defibrillators
BCBSOK-SUR707.003, Implantable Cardioverter Defibrillators
CARELON-implantable-cardioverter-defibrillators-2024-11-17-updated-2026-01-01, Implantable Cardioverter Defibrillators
Related Codes
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