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Coverage criteria policies

Automatic external defibrillator – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific 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 covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. An AED will be approved for a recipient if they have one of the following conditions with implantation of a defibrillator currently contraindicated:
    1. A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause; or
    2. A sustained ventricular tachyarrhythmia, lasting 30 seconds or longer, 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 tachyarrhythmia such as long QT syndrome or hypertrophic cardiomyopathy; or
    4. Coronary artery disease with a prior documented myocardial infarction (more than 4 weeks prior to the external defibrillator prescription) with a measured left ventricular ejection fraction less than or equal to 0.35 and inducible, sustained ventricular tachycardia or ventricular fibrillation during an EP study (tested at least 4 weeks after the most recent myocardial infarction); or
    5. Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Recipients must not have:
      1. Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
      2. Had a coronary artery bypass graft or percutaneous transluminal coronary angioplasty within the past 3 months
      3. Had an enzyme-positive MI within the past month
      4. Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
    6. Recipients with ischemic dilated cardiomyopathy, documented prior myocardial infarction, New York Heart Association Class II and III heart failure, and measured left ventricular ejection fraction ≤35%; or
    7. Recipients with nonischemic dilated cardiomyopathy for greater than 3 months, New York Heart Association Class II and III heart failure, and measured left ventricular ejection fraction ≤ 35%; or
    8. Recipients who meet one or more of the previous criteria and have New York Heart Association Class IV heart failure; or
    9. Recipient has a previously implanted defibrillator which now requires explantation and immediate replacement of the implanted defibrillator is contraindicated.

Indications that are not covered

  1. An AED will not be approved for recipients who:
    1. Currently have an implantable cardioverter- defibrillator (ICD); or
    2. Lack a caregiver who is able to correctly use the AED, and is available to promptly use the AED 24 hours per day. If the recipient does not have 24 hour awake caregivers, documentation must address how the recipient’s health will be assured during sleep hours.

Definitions

Automated External Defibrillators (AED) are used to administer an electric shock to the heart to stop ventricular fibrillation.

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.

The services associated with these codes require prior authorization:

Codes

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. Minnesota Health Care Programs (MHCP) Provider Manual: External Defibrillators. Revised 01-31-2012

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Policy activity

  • 02/23/2012 - Date of origin
  • 08/01/2017 - Effective date
Review date
  • 08/2018
Revision date
  • 07/19/2016

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