C7538 — Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
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.
5 Active Policies
A56391 — Billing and Coding: Implantable Automatic Defibrillators
J05
A56326 — Billing and Coding: Implantable Automatic Defibrillators
J06
A56340 — Billing and Coding: Implantable Automatic Defibrillators
A56343 — Billing and Coding: Implantable Automatic Defibrillators
CARELON-cardiac-resynchronization-therapy-2024-10-20
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