C7538, Insertion of new or replacement of permanent pacemaker with ventricular
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For prior-MI and cardiomyopathy primary prevention indications, document LVEF value and measurement method (echocardiography, radionuclide imaging, cardiac MRI, or catheter angiography).
- For indications B2–B5, document a formal shared decision‑making encounter using an evidence‑based decision tool between the patient and a physician or qualified non‑physician practitioner prior to initial ICD implantation.
- Document clinical stability (eg, not in shock) at time of implantation and absence of significant irreversible brain damage or non‑cardiac disease with life expectancy <1 year.
- When billing, include the applicable ICD-10-CM diagnosis codes listed in the NCD for the covered indication and for replacements include device/lead malfunction or ERI codes when applicable.
Key Coverage Criteria
- Personal history of sustained ventricular tachycardia (spontaneous or EP-induced) not associated with an acute myocardial infarction and not due to a transient or reversible cause is an indication for ICD implantation.
- Personal history of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause is an indication for ICD implantation.
- Patients with prior myocardial infarction and measured left ventricular ejection fraction (LVEF) ≤ 0.30 are indicated for ICD implantation provided they do not have NYHA class IV heart failure, have not had CABG/PCI in the past 3 months, have not had an MI within the past 40 days, and are not candidates for coronary revascularization.
- Patients with severe ischemic dilated cardiomyopathy, no prior sustained VT or VF arrest, NYHA class II or III heart failure, and LVEF ≤ 35% are indicated for ICD implantation provided they have not had CABG/PCI within 3 months, have not had MI within 40 days, and are not candidates for coronary revascularization.
- Patients with severe non-ischemic dilated cardiomyopathy, no prior sustained VT or VF arrest, NYHA class II or III heart failure, LVEF ≤ 35%, and who have been on optimal medical therapy for at least 3 months are indicated for ICD implantation provided they have not had CABG/PCI within 3 months, have not had 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 (eg, long QT syndrome, hypertrophic cardiomyopathy) are indicated for ICD implantation.
6 Active Policies
A56391, Billing and Coding: Implantable Automatic Defibrillators
J5
BCBSIL-MED202.054, Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
BCBSMT-MED202.054, Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
BCBSNM-MED202.054, Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
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