Skip to main content
HealthPartners

Coverage criteria policies

Automatic external defibrillator

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.

Administrative Process

Automatic external defibrillators (AED) require prior authorization.

Coverage

Automatic external defibrillators are generally not covered, except as described below.

Indications that are covered

  1. An automatic external defibrillator (E0617) is covered for patients in two circumstances. They meet either both criteria A and B described below or criterion C, described below:
    1. Implantation surgery is contraindicated;
    2. The patient has one of the following conditions (i-viii):
      1. A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause; or
      2. 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
      3. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy; or
      4. 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:
        1. The myocardial infarction must have occurred more than 4 weeks prior to the external defibrillator prescription; and,
        2. The EP test must have been performed more than 4 weeks after the qualifying myocardial infarction.
          -or-
      5. Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Patients must not have:
        1. Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; or
        2. Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; or
        3. Had an enzyme-positive MI within past month; or
        4. Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
        5. Irreversible brain damage from preexisting cerebral disease; or
        6. Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than one year.
          -or-
      6. 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
      7. Patients with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%; or
      8. Patients who meet one of the previous criteria (i-vii) and have NYHA Class IV heart failure.
    3. A previously implanted defibrillator now requires explantation

Indications that are not covered

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.

Definitions

Automatic external defibrillator (AED) – 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.

Class

Patient Symptoms

I

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).

II

Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).

III

Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.

IV

Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Class

Objective Assessment

A

No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.

B

Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.

C

Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.

D

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

Code

Description

E0617

External defibrillator with integrated electrocardiogram analysis

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

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.

References

  1. 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
  2. Hayes Inc, Search & Summary Home Use of Automated External Defibrillator in Pediatric Patients with Congenital Long QT Syndrome Lansdale, PA: Hayes, Inc.; January, 2017/Archived February 2018.
  3. Holmberg, M., Vognsen, M., Andersen, M., Donnino, M., Andersen, L. 2017, Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis, Resuscitation, Volume 120, Pages 77-87.
  4. Rea, T. Automated external defibrillators In: UpToDate, Page, R. (Ed), UpToDate, Waltham, MA. (Accessed on June 12, 2018.)

Go to

Policy activity

  • 02/23/2012 - Date of origin
  • 08/01/2017 - Effective date
Review date
  • 08/2018
Revision date
  • 07/15/2016

Related content