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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.

See also Biventricular Pacemakers for the Treatment of Congestive Heart Failure.

The use of the automatic implantable cardioverter defibrillator (AICD) may be considered medically necessary in patients who meet the following criteria:

Adults

Primary Prevention:

• Ischemic cardiomyopathy with New York Heart Association (NYHA) functional class II or class III symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 35% or less; or
• Ischemic cardiomyopathy with NYHA functional class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 30% or less; or
• Symptomatic nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined; or
• Hypertrophic cardiomyopathy (HCM) with one or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in 1 or more first-degree relatives younger than 50 years; left ventricular hypertrophy greater than 30 mm; 1 or more runs of nonsustained ventricular tachycardia at heart rates of 120 beats per minute or greater on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM.

Secondary Prevention:

• Patients with a history of life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia.

The use of the AICD is considered investigational in primary prevention patients who:

• Have had an acute myocardial infarction (i.e. less than 40 days before AICD treatment);
• Have New York Heart Association  (NYHA) Class IV congestive heart failure (unless patient is eligible to receive a combination cardiac resynchronization therapy ICD device;
• Have had cardiac revasculization procedure in past 3 months coronary artery bypass graft [CABG] or percutaneous transluminal coronary angioplasty [PTCA] or are candidates for a cardiac revascularization procedure or
• Have noncardiac disease that would be associated with life expectancy less than 1 year

Pediatrics

The use of the ICD may be considered medically necessary in children who meet any of the following criteria:

• Survivors of cardiac arrest, after reversible causes have been excluded; or
• Symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation; or
• Congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias.

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.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

For Coding Guidelines see the Anesthesia Coding Policy.

Covered Codes

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

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