Adults
The use of the automatic implantable cardioverter defibrillator (ICD) may be considered medically necessary in adults who meet the following criteria.
Primary Prevention
Ischemic cardiomyopathy with New York Heart Association (NYHA) functional class II or III symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 35% or less; or
Ischemic cardiomyopathy with NYHA functional class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 30% or less; or
Nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined; or
Hypertrophic cardiomyopathy (HCM) with 1 or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in ≥1 first-degree relatives younger than 50 years; left ventricular hypertrophy >30 mm; ≥1 runs of nonsustained ventricular tachycardia at heart rates of ≥120 beats per minute on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM.
Diagnosis of any one of the following cardiac ion channelopathies and considered to be at high risk for sudden cardiac death (see Policy Guidelines section):
congenital long QT syndrome; OR
Brugada syndrome; OR
short QT syndrome; OR
catecholaminergic polymorphic ventricular tachycardia.
Diagnosis of cardiac sarcoid and considered to be at high risk for sudden cardiac death (see Policy Guidelines section)
Secondary Prevention
Patients with a history of a life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia, after reversible causes (eg, acute ischemia) have been excluded.
The use of the ICD is considered investigational in primary prevention patients who:
have had an acute myocardial infarction (ie, <40 days before ICD treatment); have NYHA class IV congestive heart failure (unless patient is eligible to receive a combination cardiac resynchronization therapy ICD device); have had a cardiac revascularization procedure in past 3 months (coronary artery bypass graft or percutaneous transluminal coronary angioplasty) or are candidates for a cardiac revascularization procedure; or have noncardiac disease that would be associated with life expectancy less than 1 year. The use of the ICD for secondary prevention is considered investigational for patients who do not meet the criteria for secondary prevention. Pediatrics The use of the ICD may be considered medically necessary in children who meet any of the following criteria: survivors of cardiac arrest, after reversible causes have been excluded; symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation; or congenital heart disease with recurrent syncope of undetermined origin in the presence of ventricular dysfunction or inducible ventricular arrhythmias. HCM with 1 or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in ≥1 first-degree relatives <50 years; massive left ventricular hypertrophy based on age-specific norms; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM. diagnosis of any one of the following cardiac ion channelopathies and considered to be at high risk for sudden cardiac death (see Policy Guidelines): congenital long QT syndrome; OR Brugada syndrome; OR short QT syndrome; OR catecholaminergic polymorphic ventricular tachycardia. The use of the ICD is considered investigational for all other indications in pediatric patients. Subcutaneous Implantable Cardioverter Defibrillator (ICD) The use of a subcutaneous ICD may be considered medically necessary for adults or children who have an indication for ICD implantation for primary or secondary prevention for any of the above reasons and meet all of the following criteria: Have a contraindication to a transvenous ICD due to 1 or more of the following: (1) lack of adequate vascular access; (2) compelling reason to preserve existing vascular access (ie, need for chronic dialysis; younger patient with anticipated long-term need for ICD therapy); or (3) history of need for explantation of a transvenous ICD due to a complication, with ongoing need for ICD therapy. Have no indication forantibradycardia pacing; AND Do not have ventricular arrhythmias known or anticipated to respond to antitachycardia pacing. The use of a subcutaneous ICD is considered investigational for individuals who do not meet the criteria outlined above.
