Implantable Cardioverter Defibrillator

POLICY NUMBER

A.7.01.44

DESCRIPTION

An implantable cardioverter defibrillator (ICD) 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 to reduce the risk of sudden death. A subcutaneous ICD (S-ICD), which lacks transvenous leads, is intended to reduce lead-related complications.

Ventricular Arrhythmia and Sudden Cardiac Death

The risk of ventricular arrhythmia and sudden cardiac death (SCD) may be significantly increased in various cardiac conditions such as ischemic cardiomyopathy, particularly when associated with reduced left ventricular ejection fraction and prior myocardial infarction; nonischemic dilated cardiomyopathy with reduced left ventricular ejection fraction; hypertrophic cardiomyopathy and additional risk factors; congenital heart disease, particularly with recurrent syncope; and cardiac ion channelopathies.

TreatmentImplantable cardioverter defibrillators (ICDs) monitor a patient's heart rate, recognize ventricular fibrillation or ventricular tachycardia (VT), and deliver an electric shock to terminate these arrhythmias to reduce the risk of SCD. Indications for ICD placement can be broadly subdivided into 1) secondary prevention; i.e., use in patients who have experienced a potentially life-threatening episode of VT (near sudden cardiac death); and 2) primary prevention, i.e., use in patients who are considered at high risk for sudden cardiac death but who have not yet experienced life-threatening VT or ventricular fibrillation.

The standard ICD placement surgery involves placement of a generator in the subcutaneous tissue of the chest wall. Transvenous leads are attached to the generator and threaded intravenously into the endocardium. The leads sense and transmit information on cardiac rhythm to the generator, which analyzes the rhythm information and produces an electrical ventricular fibrillation shock when a malignant arrhythmia is recognized.

A subcutaneous ICD (S-ICD) has been developed. It does not use transvenous leads and thus avoids the need for venous access and complications associated with the insertion of venous leads. Rather, the S-ICD uses a subcutaneous electrode implanted adjacent to the left sternum. The electrodes sense the cardiac rhythm and deliver countershocks through the subcutaneous tissue of the chest wall.

Several automatic implantable cardioverter defibrillators have been approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process. The FDA-labeled indications generally include patients who have experienced life-threatening VT associated with cardiac arrest or VT associated with hemodynamic compromise and resistance to pharmacologic treatment. Also, devices typically have approval in the secondary prevention setting for patients with previous myocardial infarction and reduced ejection fraction.

Transvenous Implantable Cardioverter Defibrillators

A large number of implantable cardioverter defibrillators (ICDs) have been approved by the U.S. Food and Drug Administration (FDA) through the premarket approval (PMA) process (FDA product code: LWS). A 2014 review of the FDA approvals of cardiac implantable devices reported that, between 1979 and 2012, the FDA approved 19 ICDs (7 pulse generators, 3 leads, 9 combined systems) through new PMA applications. Many originally approved ICDs have received multiple supplemental applications. A selective summary of some currently available ICDs is provided in the table below.

In April 2021, Medtronic issued a recall of the Evera, Viva, Brava, Claria, Amplia, Compia, and Visia ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds) due to an unexpected and rapid decrease in battery life. The decrease in battery life is caused by a short circuit and will cause some devices to produce a "Recommended Replacement Time" warning earlier than expected. Some devices may progress from this warning to full battery depletion within as little as 1 day. The device may stop functioning if the user does not respond to the first warning. In August 2022, Medtronic issued a recall of the Cobalt XT, Cobalt, and Crome ICDs and CRT-Ds because of risk that the devices may issue a short circuit alert and deliver a reduced energy electric shock instead of delivering a second phase of high voltage therapy. The reduced energy electrical shock may fail to correct an arrhythmia or may cause an irregular heartbeat. In July 2023, Medtronic issued a recall of the Cobalt XT, Cobalt, Crome, Visia AF, Visia AF MRI, Evera, Evera MRI, Prio, MRI, and Mirro MRI devices (along with some CRT-D devices) due to the potential for a reduced energy shock due to inappropriate activation of the short circuit protection feature. The FDA identified all 3 of these events as Class I recalls, the most serious type of recall, indicating a situation in which use of these devices may cause serious injuries or death.

Subcutaneous Implantable Cardioverter Defibrillators

In 2012, the Subcutaneous Implantable Defibrillator (S-ICD™) System was approved by the FDA through the PMA process for the treatment of life-threatening ventricular tachyarrhythmias in patients who do not have symptomatic bradycardia, incessant ventricular tachycardia, or spontaneous, frequently recurring ventricular tachycardia that is reliably terminated with anti-tachycardia pacing (see the table below).

In 2015, the Emblem™ S-ICD (Boston Scientific), which is smaller and longer-lasting than the original S-ICD, was approved by the FDA through the PMA supplement process.

In February 2021, Boston Scientific issued a recall of the Emblem S-ICD because of increased risk of device fractures. The FDA designated the recall a Class I event, the most serious type of recall, indicating a situation in which there is a reasonable probability that the use of the device may cause serious injuries or death.

Extravascular Implantable Cardioverter Defibrillators

In 2023, the Aurora EV-ICD™ MRI SureScan device was approved by the FDA for patients who are at risk of life-threatening ventricular arrhythmias and have not had a prior sternotomy and do not need pacing. This was the first extravascular ICD to be approved in the United States. Extravascular ICD leads are placed in the anterior mediastinum rather than inside the heart or veins.

Implantable Cardioverter Defibrillators With FDA Approval

PMA: premarket application.

NOTE: ICDs may be combined with other pacing devices, such as pacemakers for atrial fibrillation, or biventricular pacemakers designed to treat heart failure. This policy addresses ICDs alone, when used solely to treat patients at risk for ventricular arrhythmias.

See also Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure .

POLICY

For Coding Guidelines see the Anesthesia Coding Policy .

Transvenous Implantable Cardioverter Defibrillator

Adults

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

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

• 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 individuals with HCM.

• Diagnosis of any one of the following cardiac ion channelopathies and considered to be at high risk for sudden cardiac death (see Policy Guidelines section):

  • congenital long QT syndrome; OR

  • Brugada syndrome; OR

  • short QT syndrome; OR

  • catecholaminergic polymorphic ventricular tachycardia.

• Diagnosis of cardiac sarcoid and considered to be at high risk for sudden cardiac death (see Policy Guidelines section).

Secondary Prevention

• Individuals with a history of a life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia, after reversible causes (eg, acute ischemia) have been excluded.

The use of the ICD is considered investigational in primary prevention individuals who:

• Have had an acute myocardial infarction (i.e. less than 40 days before ICD treatment);

• Have New York Heart Association (NYHA) Class IV congestive heart failure (unless the individual is eligible to receive a combination cardiac resynchronization therapy ICD device);

• Have had a cardiac revascularization 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.

The use of the ICD for secondary prevention is considered investigational for individuals who do not meet the criteria for secondary prevention.

Pediatrics

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

• Survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation, after reversible causes have been excluded;

• Long QT syndrome in individuals who are survivors of sudden cardiac arrest (in combination with beta-blockers);

• Long QT syndrome in individuals who cannot take beta-blockers and for whom cardiac sympathetic denervation or other medications are not considered appropriate;

• Catecholaminergic polymorphic ventricular tachycardia in individuals who experience cardiac arrest despite maximally tolerated beta-blockers, flecainide, or cardiac sympathetic denervation;

• Brugada syndrome in individuals who are survivors of sudden cardiac arrest or have documented spontaneous sustained ventricular tachycardia;

• Hypertrophic cardiomyopathy in individuals who are survivors of sudden cardiac arrest or have documented spontaneous sustained ventricular tachycardia;

• Arrhythmogenic cardiomyopathy in individuals who are survivors of sudden cardiac arrest or sustained ventricular tachycardia that is not hemodynamically tolerated;

• Nonischemic dilated cardiomyopathy in individuals who are survivors of sudden cardiac arrest or have documented spontaneous sustained ventricular tachycardia that is not due to completely reversible causes;

• Congenital heart disease in individuals who are survivors of sudden cardiac arrest, after reversible causes have been excluded;.

• Symptomatic, sustained ventricular tachycardia in association with congenital heart disease in individuals who have undergone hemodynamic and electrophysiologic evaluation.

The use of the ICD is considered investigational for all other indications in pediatric individuals.

Subcutaneous ICD

The use of a subcutaneous ICD may be considered medically necessary for adult or pediatric individuals who have an indication for ICD implantation for primary or secondary prevention for any of the above reasons and meet all of the following criteria:

• Have a contraindication to a transvenous ICD due to one or more of the following: (1) lack of adequate vascular access; (2) compelling reason to preserve existing vascular access (ie, need for chronic dialysis; younger individual with anticipated long-term need for ICD therapy); or (3) history of need for explantation of a transvenous ICD due to a complication, with ongoing need for ICD therapy.

• Have no indication for antibradycardia pacing; AND

• Do not have ventricular arrhythmias known or anticipated to respond to antitachycardia pacing.

The use of a subcutaneous ICD is considered investigational for individuals who do not meet the criteria outlined above.

Extravascular Implantable Cardioverter Defibrillator

The use of an extravascular ICD is considered investigational.

POLICY EXCEPTIONS

Federal 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 GUIDELINES

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

This policy addresses the use of implantable cardioverter defibrillator (ICD) devices as stand-alone interventions, not as combination devices to treat heart failure (ie, cardiac resynchronization devices) or in combination with pacemakers. Unless specified, the policy statements refer to transvenous ICDs.

Indications for pediatric ICD use are based on the 2021 Pediatric and Congenital Electrophysiology Society and Heart Rhythm Society guidance on ICDs in children.

Criteria for Implantable Cardioverter Defibrillator Implantation in Individuals With Cardiac Ion Channelopathies

Individuals with cardiac ion channelopathies may have a history of a life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia, after reversible causes, in which case they should be considered for ICD implantation for secondary prevention, even if they do not meet criteria for primary prevention.

Criteria for ICD placement in individuals with cardiac ion channelopathies derive from results of clinical input, a 2013 consensus statement from the HRS, European Heart Rhythm Association (EHRA), and the Asia-Pacific Heart Rhythm Society on the diagnosis and management of individuals with inherited primary arrhythmia syndromes, and a report from the HRS and EHRA’s Second Consensus Conference on Brugada syndrome.

Indications for consideration for ICD placement for each cardiac ion channelopathy are as follows:

• Long QT syndrome (LQTS):

  • Individuals with a diagnosis of LQTS who are survivors of cardiac arrest.

  • Individuals with a diagnosis of LQTS who experience recurrent syncopal events while on beta-blocker therapy.

• Brugada syndrome (BrS):

  • Individuals with a diagnosis of BrS who are survivors of cardiac arrest.

  • Individuals with a diagnosis of BrS who have documented spontaneous sustained ventricular tachycardia (VT) with or without syncope.

  • Individuals with a spontaneous diagnostic type 1 electrocardiogram (ECG) who have a history of syncope, seizure, or nocturnal agonal respiration judged to be likely caused by ventricular arrhythmias (after noncardiac causes have been ruled out).

  • Individuals with a diagnosis of BrS who develop ventricular fibrillation (VF) during programmed electrical stimulation.

• Catecholaminergic polymorphic ventricular tachycardia (CPVT):

  • Individuals with a diagnosis of CPVT who are survivors of cardiac arrest.

  • Individuals with a diagnosis of CPVT who experience recurrent syncope or polymorphic/bidirectional ventricular tachycardia (VT) despite optimal medical management, and/or left cardiac sympathetic denervation.

• Short QT syndrome (SQTS):

  • Individuals with a diagnosis of SQTS who are survivors of cardiac arrest.

  • Individuals with a diagnosis of SQTS who are symptomatic and have documented spontaneous VT with or without syncope.

  • Individuals with a diagnosis of SQTS who are asymptomatic or symptomatic and have a family history of sudden cardiac death.

NOTE: For congenital LQTS, individuals may have one or more clinical or historical findings other than those outlined above that could, alone or in combination, put them at higher risk for sudden cardiac death. They can include individuals with a family history of sudden cardiac death due to LQTS, infants with a diagnosis of LQTS with functional 2:1 atrioventricular block, individuals with a diagnosis of LQTS in conjunction with a diagnosis of Jervell and Lange-Nielsen syndrome or Timothy syndrome, and individuals with a diagnosis of LQTS with profound QT prolongation (>550 ms). These factors should be evaluated on an individualized basis by a clinician with expertise in LQTS when considering the need for ICD placement.

Criteria for Implantable Cardioverter Defibrillator Implantation in Individuals With Cardiac Sarcoid

Criteria for ICD placement in individuals with cardiac sarcoid derive from a 2014 consensus statement from the Heart Rhythm Society (HRS) and 2017 joint guidelines from the American Heart Association, American College of Cardiology, and HRS.

Indications for consideration of ICD placement in individuals diagnosed with cardiac sarcoid are as follows:

• Spontaneous sustained ventricular arrhythmias, including prior cardiac arrest, if meaningful survival of greater than 1 year is expected;

• LVEF 35% or less, despite optimal medical therapy and a period of immunosuppression (if there is active inflammation), if meaningful survival of greater than 1 year is expected;

• LVEF greater than 35%, if meaningful survival of greater than 1 year is expected; AND

  • syncope or near-syncope, felt to be arrhythmic in etiology OR

  • evidence of myocardial scar by cardiac MRI or positron emission tomographic (PET) scan; OR

  • inducible sustained ventricular arrhythmias (>30 seconds of monomorphic VT or polymorphic VT) or clinically relevant ventricular fibrillation.

• An indication for permanent pacemaker implantation.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

6/1997: 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 hypertrophic 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.

12/13/2013: Policy reviewed; no changes.

03/19/2014: Policy reviewed; no changes.

05/07/2014: Policy reviewed; description updated regarding standard and subcutaneous ICDs. Moved the first medically necessary policy statement under the adults section and replaced the word "patients" with "adults." Deleted the word "symptomatic" from the statement in the primary prevention criteria. It previously stated: 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. Added "after reversible causes (eg, acute ischemia) have been excluded" to the policy statement on secondary prevention in adults.

12/03/2014: Policy title changed from "Automatic Implantable Cardioverter Defibrillator (AICD)" to "Implantable Cardioverter Defibrillator." Wording changed throughout policy to be consistent with policy title. Policy description updated regarding FDA approval of ICDs. Policy statements unchanged.

12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 33216, 33217, 33240, 33241, 33243, 33244, and 33249. Effective 01/01/2015. Added the following new 2015 CPT codes to the Code Reference section: 33270, 33271, 33272, 33273, 93260, 93261, and 93644.

08/28/2015: Code Reference section updated for ICD-10. Removed deleted CPT code 33242.

06/08/2016: Policy number A.7.01.44 added. Policy Guidelines updated to add medically necessary and investigative definitions. Removed deleted CPT codes 0319T - 0328T from the Investigational Codes table.

08/15/2016: Policy description updated regarding subcutaneous ICDs. Primary prevention for adults policy statement updated to state that AICD may be medically necessary for the diagnosis of cardiac ion channelopathies with conditions. Added investigational statement for the use of the ICD for secondary prevention for patients who do not meet criteria. Policy statement for pediatrics updated to add hypertrophic cardiomyopathy and the diagnosis of cardiac ion channelopathies with conditions as medically necessary indications. Subcutaneous ICD policy statement changed from investigational to medically necessary with certain conditions. Revised policy statement to state that the use of subcutaneous ICD is considered investigational for individuals who do not meet the criteria outlined above. Policy guidelines updated regarding criteria for ICD implantation in patients with cardiac ion channelopathies. Moved the following CPT codes from investigational to covered: 33270, 33271, 33272, 33273, 93260, 93261, and 93644. Added ICD-10 procedure codes 0JH60PZ, 0JH63PZ, and 0JWT0PZ. Removed Investigational Codes table.

09/30/2016: Code Reference section updated to add new ICD-10 procedure codes 02PA0NZ, 02PA3NZ, and 02PA4NZ.

12/30/2016: Code Reference section updated to add new 2017 CPT code 0453T.

06/20/2017: Policy description updated regarding increased risk of ventricular arrhythmia and sudden cardiac death in various cardiac conditions. Policy statements unchanged.

06/18/2018: Policy description updated. Policy statements unchanged. Policy Guidelines updated.

06/10/2019: Policy statements unchanged. Policy Guidelines updated.

09/24/2019: Code Reference section updated to add new ICD-10 procedure codes 0JH60FZ, 0JH63FZ, 0JPT0FZ, 0JPT3FZ, and 0JWT0FZ, effective 10/01/2019.

11/21/2019: Code Reference section updated to remove ICD-10 procedure codes 02PA0NZ, 02PA3NZ, and 02PA4NZ.

05/18/2021: Policy statement updated to state that the use of an automatic implantable cardioverter defibrillator may be medically necessary in adults with a diagnosis of cardiac sarcoid and considered to be at high risk for sudden cardiac death. Policy Guidelines updated regarding criteria for implantable cardioverter defibrillator implantation in patients with cardiac sarcoid. Code Reference section updated to add ICD-10 diagnosis code D86.85.

08/24/2021: Policy description updated regarding subcutaneous ICD devices. Policy statements unchanged.

12/10/2021: Code Reference section updated to make note of deleted code.

06/21/2022: Policy reviewed. Medically necessary policy statements updated to change "adults" to "patients" and "children" to "pediatric patients."

09/21/2022: Code Reference section updated to add new ICD-10 diagnosis codes I47.20, I47.21, and I47.29, effective 10/01/2022.

07/14/2023: Policy description updated regarding transvenous implantable cardioverter defibrillators. Policy statements and Policy Guidelines updated to change "patients" to "individuals." Code Reference section updated to remove deleted CPT code 0453T.

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes I47.10, I47.11, and I47.19, effective 10/01/2023.

08/28/2024: Policy description updated regarding devices. Policy section updated to revise pediatric criteria and to add an investigational statement for the use of an extravascular implantable cardioverter defibrillator. Policy Guidelines updated regarding indications for pediatric ICD use. Code Reference section updated to remove deleted ICD-10 diagnosis code I47.2. Added ICD-10 diagnosis codes I42.2, I42.8, I42.9, I46.2, I46.8, I46.9, I49.9, Q20.0 - Q20.9, Q21.0 - Q21.9, Q22.0 - Q22.9, Q23.0 - Q23.9, and Q24.0 - Q24.9.

08/14/2025: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code I47.1.

SOURCE(S)

Blue Cross Blue Shield Association Policy # 7.01.44

CODE REFERENCE

This 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 .

Covered Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.