Criteria
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 and ANY ONE of the following criteria:
As a bridge to cardiac transplantation where documentation supports active transplantation listing.
OR
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.
OR
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.
OR
Either documented prior myocardial infarction or nonischemic cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 35%.
OR
Familial or isolated hypertrophic cardiomyopathy with a high risk for life-threatening ventricular tachyarrhythmias where a current medical contraindication to definitive device implantation exists.
OR
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.
Procedure Codes
| 93292 |
93745 |
K0606 |
K0608 |
K0609 |
