Coverage is subject to the specific terms of the member's benefit plan.
Coverage beyond 90 days for an additional 30 days will be given individual consideration based upon additional documentation.
A WCD may be considered medically necessary for a period of up to three (3) months and when ALL of the following criteria are met:
- At least one (1) years of age or older; and
- Documentation from a cardiovascular disease provider that the individual currently qualifies for an implantable defibrillator but has a current medical contraindication to device implantation.
As a bridge to cardiac transplantation where documentation supports active transplantation listing.
Inherited channelopathies or familial Sudden Cardiac Arrest (SCA) with a high risk for life-threatening ventricular tachyarrhythmias where a current medical contraindication to definitive device implantation exists.
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.
Either documented prior myocardial infarction or nonischemic cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 35%.
Familial or isolated hypertrophic cardiomyopathy with a high risk for life-threatening ventricular tachyarrhythmias where a current medical contraindication to definitive device implantation exists
A previously implanted defibrillator now requires explanation;
WCD usage should not be secondary to transient or reversible causes including but not limited to the following:
- Transient ischemia or within 48 hours of myocardial infarction; or
- Drug toxicity; or
- Severe hypoxia; or
- Acidosis; or
- Hypokalemia; or
- Hypercalcemia; or
- Hyperkalemia; or
- Systemic infections.
A WCD not meeting the criteria as indicated in this policy is considered not medically necessary.