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National Coverage Determination (NCD)

Implantation of Automatic Defibrillators

35-85

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Tracking Information

Publication Number
6
Manual Section Number
35-85
Manual Section Title
Implantation of Automatic Defibrillators
Version Number
1
Effective Date of this Version
07/01/1999
Ending Effective Date of this Version
10/01/2003
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Physicians' Services
Prosthetic Devices


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

The 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.
Indications and Limitations of Coverage

Effective for services performed on or after January 24, 1986 through July 1, 1991, the implantation of an automatic defibrillator (ICD-9-CM codes 37.94-37.96 or CPT code 33246) is a covered service only when used as a treatment of last resort for patients who have had a documented episode of life-threatening ventricular tachyarrhythmia or cardiac arrest not associated with myocardial infarction. Patients must also be found, by electrophysiologic testing, to have an inducible tachyarrhythmia that proves unresponsive to medication or surgical therapy (or be considered unsuitable candidates for surgical therapy). It must be emphasized that unless all of the above described conditions and stipulations are met in a particular case, including the inducibility of tachyarrhythmia, etc., implantation of an automatic defibrillator may not be covered.

Effective for services performed on or after July 1, 1991, the implantation of an automatic defibrillator is a covered service for patients who have had a documented episode of life-threatening ventricular tachyarrhythmia or cardiac arrest not associated with myocardial infarction.

Effective for services performed on or after July 1, 1999, the implantation of an automatic defibrillator is also a covered service for patients with the following conditions:

  1. A documented episode of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause;
  2. Ventricular tachyarrhythmia, either spontaneous or induced, not due to a transient or reversible cause; or,
  3. Familial or inherited conditions with a high risk or life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
115
Revision History

04/1999 - Expanded coverage for additional types of cardiac patients. Effective date 07/01/1999. Effective date 07/01/1999. (TN 115) (CR 825)

01/1986 - Provided coverage to treat life-threatening ventricular tachyarrhythmias. Effective date 01/24/1986. (TN 3)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Implantable Cardioverter Defibrillators (ICDs) 5 07/31/2023 - N/A View
Implantable Cardioverter Defibrillators (ICDs) 4 02/15/2018 - 07/31/2023 View
Implantable Automatic Defibrillators 3 01/27/2005 - 02/15/2018 View
Implantable Automatic Defibrillators 2 10/01/2003 - 01/27/2005 View
Implantation of Automatic Defibrillators 1 07/01/1999 - 10/01/2003 You are here
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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