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DESCRIPTIONThe Automatic Implantable Cardioverter Defibrillator (AICD) is a device designed to monitor a patient's heart rate, recognize ventricular fibrillation or ventricular tachycardia, and deliver an electric shock to terminate these arrhythmias in order to reduce the risk of sudden death. Indications for AICD implantation can be broadly subdivided into 1) secondary prevention; i.e., their use in patients who have experienced a potentially life-threatening episode of ventricular tachyarrhythmia; and 2) primary prevention; i.e., their use in patients who are considered at high risk for sudden cardiac death but who not yet experienced life-threatening ventricular tachycardia (VT) or ventricular fibrillation (VF).
There are several FDA-approved automatic implantable cardioverter defibrillators. Indications generally include patients who have experienced life-threatening ventricular tachyarrhythmia associated with cardiac arrest, or ventricular tachyarrhythmia associated with hemodynamic compromise and resistance to pharmacologic treatment. Devices manufactured by Guidant are approved by the FDA for use in "patients at high risk of sudden cardiac death due to ventricular arrhythmias and who have experienced at least one of the following: an episode of cardiac arrest (manifested by the loss of consciousness) due to a ventricular tachyarrhythmia; recurrent, poorly tolerated sustained ventricular tachycardia (VT); or a prior myocardial infarction, left ventricular ejection fraction of less than or equal to 35%, and a documented episode of nonsustained ventricualr tachycardia (VT), with an inducible ventricular tachyarrhythmia." On July 18, 2002, the FDA expanded the approved indications for the Guidant AICD devices to include the prophylactic use of Guidant ICDs for cardiac patients who have had a previous heart attack and have an ejection fraction that is less than or equal to 30%. This expanded indication is based on the results of the MADIT II trial. Medtronic devices are approved "to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias." Other devices have approval language similar to Medtronic.
NOTE: AICDs may be combined with other pacing devices, such as pacemakers for atrial fibrillation, or biventricular pacemakers designed to treat congestive heart failure. This policy addresses AICDs alone, when used solely to treat patients at risk for ventricular arrhythmias.
POLICYFor Coding Guidelines see the Anesthesia Coding Policy.
The use of the automatic implantable cardioverter defibrillator (AICD) may be considered medically necessary in patients who meet the following criteria:
The use of the AICD is considered investigational in primary prevention patients who:
The use of the ICD may be considered medically necessary in children who meet any of the following criteria:
The use of the ICD is considered investigational for all other indications in pediatric patients.
The use of a subcutaneous ICD is considered investigational for all indications in adult and pediatric patients.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY6/1997: Approved by the Medical Policy Advisory Committee (MPAC)
4/18/2002: Type of Service and Place of Service deleted
9/2/2003: Code Reference section updated, CPT 33247 deleted
11/2003: Reviewed by MPAC, policy coverage aligned to be consistent with Centers for Medicare & Medicaid Services, "Description" section revised to be consistent with BCBSA, FEP Exception added
2/27/2004: Code Reference section updated
11/16/2005: Code Reference section updated, ICD9 diagnosis code 426.82 added
5/18/2006: Policy revised. Revisions approved by the Medical Policy Advisory Committee (MPAC)
12/27/2006: Code Reference section updated per the 2007 CPT revisions
12/13/2007: Policy reviewed and hypertorphic cardiomyopathy section added
7/18/2008: Anesthesia Coding Policy hyperlink added
12/19/2008: Policy reviewed, no changes
06/03/2010: Policy description and policy statement unchanged. Added the definition of investigative service to the policy guidelines. Deleted outdated references from the Sources sections. FEP verbiage added to the Policy Exceptions section. Added CPT codes 33216 and 33217.
08/23/2011: Policy statement revised to clarify the indications in ischemic cardiomyopathy, with separate indications for class II/III and class I patients. Policy statement regarding waiting time in nonischemic cardiomyopathy was revised to remove the specification of a 9-month waiting period. Added policy statement to outline coverage criteria for ICD in pediatric patients.
01/09/2013: Added policy statement to indicate that the use of a subcutaneous ICD is considered investigational for all indications in adult and pediatric patients. Added 0319T - 0328T to the Code Reference section as non-covered.
05/06/2013: Added ICD-9 codes 414.8, 425.4, and V12.53 to the Covered Codes table.
SOURCE(S)Blue Cross Blue Shield Association Policy #7.01.44
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
For Coding Guidelines see the Anesthesia Coding Policy.
This is not an all-inclusive list of non-covered procedure codes.
The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.
Non- Covered Codes