These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Wearable cardioverter defibrillators do not require prior authorization.
Automatic external defibrillators (non-wearable) require prior authorization.
Wearable cardioverter defibrillators are generally covered per the criteria listed below.
Automatic external defibrillators are generally not covered, except as described below.
- Wearable cardioverter defibrillator:
A wearable cardioverter defibrillator (WCD) is considered medically necessary when ordered by a cardiologist and one of the following criteria is met:
- The individual is at high risk for sudden cardiac death (SCD) and meets criteria for implantable cardioverter defibrillator (ICD) placement but is not currently a suitable candidate for ICD placement because of one of the following:
- awaiting heart transplantation; or
- awaiting ICD re-implantation following infection-related explantation; or
- systemic infectious process or other temporary medical condition precludes implantation; or
- A previously implanted defibrillator now requires explantation.
- Covered from the date of hospital discharge for up to 6 months as a bridge to ICD risk stratification and possible implantation for patients with left ventricular ejection fraction (LVEF) less than or equal to 35% when one of the following applies:
- Following myocardial infarction (MI); or
- Following coronary artery bypass graft (CABG); or
- New diagnosis of cardiomyopathy (within 30 days of request for WCD); or
- Following percutaneous transluminal coronary angioplasty (PTCA).
- Exceptions will be considered on a case by case basis.
- Covered for pediatric members who are at least 8 years of age and weigh at least 41 pounds when ordered by a cardiologist, and when member meets criteria under section A or section B above.
- Non-wearable automatic external defibrillator:
A nonwearable automatic defibrillator (E0617) is covered for patients in two circumstances. They meet either both criteria A and B described below or criterion C, described below:
- Implantation surgery is contraindicated;
- The patient has one of the following conditions (i-viii):
- A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause; or
- 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; or
- Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy; or
- 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. Patients 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.
- Patients 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%; or
- Patients with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%; or
- Patients who meet one of the previous criteria (i-vii) and have NYHA Class IV heart failure.
- A previously implanted defibrillator now requires explantation
- Wearable cardioverter defibrillators for any other indication, including but not limited to a diagnosis of cardiomyopathy greater than 30 days old because there is not scientific evidence proving its efficacy.
- Automatic external defibrillator (AED) whose primary use is a safety device kept in the home as a precautionary measure to address a possible acute event, rather than a device needed for active treatment. An AED in the home is generally not considered medically necessary, except as described above in the covered section.
Wearable cardioverter defibrillator (WCD) – a device worn by patients at risk for sudden cardiac arrest (SCA), allowing their physician time to assess their long-term arrhythmic risk and make appropriate plans. The wearable cardioverter-defibrillator is an external device capable of automatic detection and defibrillation of ventricular tachycardia (VT) or ventricular fibrillation (VF). The WCD is composed of four dry, nonadhesive monitoring electrodes, three defibrillation electrodes incorporated into a chest strap assembly, and a defibrillation unit carried on a waist belt. The monitoring electrodes are positioned circumferentially around the chest, held in place by tension from an elastic belt, and provide two surface electrocardiogram leads. The defibrillation electrodes are positioned in a vest assembly for apex-posterior defibrillation. Proper fitting is required to achieve adequate skin contact to avoid noise and frequent alarms. If an arrhythmia is detected, an escalating alarm sequence occurs, including a vibration against the skin and audible tones. Patients are trained to hold a pair of response buttons during these alarms to avoid receiving a shock while awake. A patient's response serves as a test of consciousness; if no response occurs and a shock is indicated, the device charges, extrudes gel from the defibrillation electrodes, and delivers up to five biphasic shocks at preprogrammed energy levels (ranging from 75 to 150 joules).
Automatic external defibrillator (AED), nonwearable – A device that automatically analyzes the heart rhythm and, if it detects a problem that may respond to an electrical shock, that permits a shock to be delivered to restore a normal heart rhythm. Thanks to their small size and ease of use, AEDs have been installed in many settings (such as schools and airports).
New York Heart Association Classes of Heart Failure – Doctors usually classify patients' heart failure according to the severity of their symptoms. The table below describes the most commonly used classification system, the New York Heart Association (NYHA) Functional Classification. It places patients in one of four categories based on how much they are limited during physical activity.
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.
If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.
Requires prior authorization
External defibrillator with integrated electrocardiogram analysis
Does not require prior authorization
Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
Replacement accessories for garment-type defibrillator
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- American Heart Association. (2017). Classes of heart failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.V4kBV_krJph
- Collins, K. K., Silva, J. N., Rhee, E. K., & Schaffer, M.S. (2010). Use of a wearable automated defibrillator in children compared to young adults. PACE, 33(9), 1119–1124 doi: 10.1111/j.1540-8159.2010.02819.x
- Chung, M. K. Wearable cardioverter-defibrillator. In: UpToDate, Page, R. L. (Ed), UpToDate, Waltham, MA. (Accessed on 7/11/2016).
- Duncker, D., König, T., Hohmann, S., Bauersachs, J., & Veltmann, C. (2017). Avoiding untimely implantable cardioverter/deﬁbrillator implantation by intensiﬁed heart failure therapy optimization supported by the wearable cardioverter/deﬁbrillator: the PROLONG study. Journal of the American Heart Association, 6(e004512), 1-8. doi: 10.1161/JAHA.116.004512
- ECRI Institute. (2011). Wearable defibrillator effective in preventing sudden cardiac death in patients following ICD explant. Plymouth Meeting, PA. ECRI Institute.
- ECRI Institute. (2013). LifeVest wearable defibrillator (Zoll Medical Corp.) for detecting and treating ventricular arrhythmia. Plymouth Meeting, PA. ECRI Institute.
- Everitt, M. D. & Saarel, E. V. (2010). Use of the wearable external cardiac defibrillator in children. PACE, 33(6), 742–746. doi: 10.1111/j.1540-8159.2010.02702.x
- Hayes, Inc. Hayes Health Technology Brief. LifeVest System (Asahi Kasei Corp.) Wearable Cardiac Defibrillator for Prevention of Sudden Cardiac Arrest. Lansdale, PA: Hayes, Inc.; October, 2012. Reviewed September, 2014/ Archived November, 2015.
- Kao, A. C., Krause, S. W., Handa, R., Karia, D., Reyes, G., Bianco, N. R., & Szymkiewicz, S. J. (2012). Wearable defibrillator use in heart failure (WIF): results of a prospective registry. BMC Cardiovascular Disorders, 12(123), 1-7. doi:10.1186/1471-2261-12-123
- Klein, H. U., Goldenberg, I., & Moss, A. J. (2013). Risk stratification for implantable cardioverter defibrillator therapy: the role of the wearable cardioverter-defibrillator. European Heart Journal, 34(29), 1-14. doi:10.1093/eurheartj/eht167
- Kutyifa, V., Moss, A. J., Klein, H., Biton, Y., McNitt, S., MacKecknie, B., … Goldenberg, I. (2015). Use of the wearable cardioverter defibrillator in high-risk cardiac patients: data from the prospective registry of patients using the wearable cardioverter defibrillator (WEARIT-II registry). Circulation, 132(17), 1613-1619. doi: 10.1161/CIRCULATIONAHA.115.015677
- Piccini, J. P., Allen, L. A., Kudenchuk, P. J., Page, R. L., Patel, M. R., & Turakhia, M. P. (2016). Wearable cardioverter-defibrillator therapy for the prevention of sudden cardiac death: a science advisory from the American Heart Association. Circulation, 133, 1-13. DOI: 10.1161/CIR.0000000000000394
- U.S. Food and Drug Administration. (2015). Device approvals and clearances. LifeVest Wearable Cardioverter Defibrillator - P010030/S056. Retrieved from https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm458494.htm
- Zishiri, E. T., Williams, S., Cronin, E. M., Blackstone, E. H., Ellis, S. G., Roselli, E. E., … Chung, M. K. (2012). Early risk of mortality after coronary artery revascularization in patients with left ventricular dysfunction and potential role of the wearable cardioverter defibrillator. Circulation: Arrhythmia and Electrophysiology, 6, 1-34. doi: 10.1161/CIRCEP.112.973552