For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
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The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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Refer to the Supplier Manual for additional information on documentation requirements.
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Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Automatic external defibrillators are covered for beneficiaries at high risk for sudden cardiac death (SCD) due to one of the conditions described under I or II. It is expected the treating practitioner be experienced in the management of beneficiaries at risk for SCD.
- A wearable defibrillator (K0606) is covered for beneficiaries if they meet one of the criteria (1-4), described below:
- 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
- Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long QT syndrome or hypertrophic cardiomyopathy; or
- Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 0.35; or
- A previously implanted defibrillator now requires explantation
Refer to the ICD-10 Codes section in the LCD-related Policy Article for applicable diagnoses.
- A nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
- The beneficiary has one of the following conditions (1-8):
- A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause
- A sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia, either spontaneous or induced during an electrophysiologic (EP) study, not associated with acute myocardial infarction, and not due to a transient or reversible cause
- Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy
- Coronary artery disease with a documented prior myocardial infarction with a measured left ventricular ejection fraction less than or equal to 0.35, and inducible, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during an EP study. To meet this criterion;
- The myocardial infarction must have occurred more than 4 weeks prior to the external defibrillator prescription; and,
- The EP test must have been performed more than 4 weeks after the qualifying myocardial infarction.
- Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Beneficiaries must not have:
- Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; or,
- Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; or,
- Had an enzyme-positive MI within past month; or,
- Clinical symptoms or findings that would make them a candidate for coronary revascularization; or,
- Irreversible brain damage from preexisting cerebral disease; or,
- Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than one year.
- Beneficiaries with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI), New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) ≤ 35%.
- Beneficiaries with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%
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Beneficiaries who meet one of the previous criteria (1-7) and have NYHA Class IV heart failure
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Implantation surgery is contraindicated
- A previously implanted defibrillator now requires explantation
Refer to the ICD-10 Codes section in the LCD-related Policy Article for applicable diagnoses.
Claims for defibrillators for other indications will be denied as not reasonable and necessary.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
