Defibrillator – Senior Plans

An implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating.

Criteria for Coverage

Defibrillators are covered for patients with:

• A documented episode of cardiac arrest due to ventricular fibrillation (VF), not due to a transient or reversible cause
• Documented sustained ventricular tachyarrhythmia (VT), either spontaneous or induced by an electrophysiology (EP) study, not associated with an acute myocardial infarction and not due to a transient or reversible cause
• Documented familial or inherited indications with a high risk of life-threatening VT, such as long Q-T syndrome or hypertropic cardiomyopathy

In addition, services performed on or after October 1, 2003, are covered for patients with:

• Coronary artery disease with a documented prior myocardial infarction (MI), a measured left ventricular ejection fraction = 0.35, and inducible, sustained VT or VF during an EP study. (The MI must have occurred more than four weeks prior to defibrillator insertion. The EP study must be performed more than four weeks after the MI.)
• Documented prior MI and a measured left ventricular ejection fraction = 0.30 and a QRS duration of > 120 milliseconds

Benefit Limitations

Coverage is not provided if any of the following circumstances apply:

• The patient meets the criteria for the New York Heart Association classification IV
• The patient experiences cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
• A coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) was performed on the patient within past three months
• The patient has had an enzyme-positive MI within the past month
• The patient has clinical symptoms or findings that exclude the patient as a candidate for coronary revascularization
• The patient has an existing disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival of less than one year
• The presence of irreversible brain damage, disease, or dysfunction precludes the patient from giving informed consent

Claims Filing Instructions

The following CPT codes should be billed for the insertion of a defibrillator:

Although Medicare requires providers to use modifier KZ (new coverage not implemented by managed care) when submitting a claim to them, contracted 65C Plus providers should not use modifier KZ when filing a claim to HMSA for 65C Plus members. Use of this modifier may delay claims payment.

Documentation Requirements

The patient record must show MIs, documented by elevated cardiac enzymes or Q-waves on an electrocardiogram. Ejection fractions must be measured by angiography, radionuclide scanning, or echocardiography. It is not necessary to include clinical notes when filing the claim.

Revision History