Coverage is subject to the specific terms of the member's benefit plan.
A WCD may be considered medically necessary for a period of up to three (3) months and when the following criteria are met:
- At least one (1) years of age or older; and
- At high risk for sudden cardiac death (SCD); and
- Requires the WCD as interim treatment for those who meet the criteria for an ICD; and ANY ONE of the following criteria:
A documented episode of ventricular fibrillation or a sustained (lasting 30 seconds or longer) ventricular tachyarrhythmia. These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute myocardial infarction. Transient or reversible causes including but not limited to:
- Drug toxicity; or
- Severe hypoxia; or
- Acidosis; or
- Hypokalemia; or
- Hypercalcemia; or
- Hyperkalemia; or
- Systemic infections; or
A previously implanted defibrillator now requires explanation;
As a bridge to left ventricular (LV) improvement for ANY ONE of the following indications:
- LV ejection fraction (EF) less than or equal to 35% after cardiac events such as:
- After recent acute myocardial infarction (MI) during the 40-day period under which ICD implantation is not indicated or deferred. Reevaluation of LVEF must occur no later than three (3) months after a MI. If LVEF remains less than or equal to 35%, an ICD is indicated; or
- Coronary revascularization procedures such as before and after coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) during the 90-day ICD waiting period; or
- Recently diagnosed non-ischemic cardiomyopathy during the three (3)-month to nine (9)-month period awaiting LV improvement or ICD implantation; or
- Heart transplantation; or
- As an alternative to an ICD in an individual who has a documented contraindication to an ICD (e.g., systemic infection, lack of vascular access).
Inherited or familial conditions with a high risk for life-threatening ventricular tachyarrhythmias.
High-risk factors as evidenced by ANY ONE of the following:
- Hypertrophic cardiomyopathy; or
- Long QT Syndrome; or
- A family history of ANY ONE of the following:
- SCD in a first degree relative (e.g., sibling, parent or child) less than 40; or
- SCD in a first degree relative (e.g., sibling, parent or child) with hypertrophic cardiomyopathy; or
- LV/septal thickness greater than three (3) cm in adults; or
- LV/Septal thickness greater than two (2) standard deviations outside of normal parameters in children, or
- Abnormal exercise blood pressure (BP) including failure BP to rise greater than 25mmHg from baseline or decrease less than10mmHg from the maximal BP during exercise.
WCD for any other indications will be considered not medically necessary.
“Coverage beyond 90 days for an additional 30 days will be given individual consideration based upon additional documentation.