A wearable cardioverter-defibrillator (WCD) is a temporary, external device. It is intended for temporary use while clinical conditions, for example, infection, preclude permanent implantable cardioverter- defibrillator (ICD) placement.
A WCD may be considered medically necessary for a period of up to three (3) months and when ALL of the following criteria are met:
As a bridge to cardiac transplantation, where documentation supports active transplantation listing.
OR
Inherited channelopathies or familial Sudden Cardiac Arrest (SCA) with a high risk for life-threatening ventricular tachyarrhythmias where a current medical contraindication to definitive device implantation exists.
OR
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
Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 35%.
OR
Familial or isolated hypertrophic cardiomyopathy with a high risk for life-threatening ventricular tachyarrhythmias where a current medical contraindication to definitive device implantation exists
OR
A previously implanted defibrillator now requires explantation.
WCD usage should not be secondary to transient or reversible causes including but not limited to the following:
A WCD not meeting the criteria as indicated in this policy is considered not medically necessary.
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New York Heart Association Functional Classification (NYHA) of Heart Disease
Classification |
Characteristics |
Class I (mild) |
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, rapid/irregular heartbeat (palpitation) or shortness of breath (dyspnea). |
Class II (mild) |
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, rapid/irregular heartbeat (palpitation), or shortness of breath (dyspnea). |
Class III (moderate) |
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, rapid/irregular heartbeat (palpitation), and shortness of breath (dyspnea). |
Class IV (severe) |
Inability to carry on any physical activity without discomfort. Symptoms of fatigue, rapid/irregular heartbeat (palpitation) or shortness of breath (dyspnea) are present at rest. If any physical activity is undertaken, discomfort increases. |
Modified Ross Heart Failure Classification for Children
Classification |
Characteristics |
Class I |
No limitations or symptoms. |
Class II |
Infants: Mild tachypnea or diaphoresis with feeding. Older children: Mild to moderate dyspnea on exertion. |
Class III |
Infants: Growth failure and marked tachypnea or diaphoresis with feeding. Older children: Marked dyspnea on exertion. |
Class IV |
Symptoms at rest such as tachypnea, retractions, grunting, or diaphoresis. |
*All documentation include daily wear time must be maintained in the medical record and be available upon request. Beginning with the initial date the device was worn for continuous monitoring; the Cardiologist must reevaluate the need for continued use of the WCD at three (3) months and again at 90 day intervals until the device is discontinued. Documentation requirements including but not limited to the following must be maintained in the medical record: the date the device was first worn for continuous monitoring, the initial indication establishing medical necessity, member tolerance and compliance throughout the use of the WCD as documented by Cardiologist evaluations.
The Cardiologist may access the Zoll LifeVest Network on-line patient management system allowing for monitoring of the individual’s data reports downloaded from a the LifeVest wearable defibrillator.
Covered Diagnosis Codes for Procedure Codes 93292, 93745, K0606:
A18.84 |
I21.3 |
I21.4 |
I21.9 |
I21.01 |
I21.02 |
I21.09 |
I21.11 |
I21.19 |
I21.21 |
I21.29 |
I21.A1 |
I21.A9 |
I22.0 |
I22.1 |
I22.2 |
I22.8 |
I22.9 |
I25.2 |
I40.0 |
I40.1 |
I40.8 |
I40.9 |
I42.0 |
I42.1 |
I42.2 |
I42.3 |
I42.4 |
I42.5 |
I42.6 |
I42.7 |
I42.8 |
I42.9 |
I43 |
I45.81 |
I46.2 |
I46.8 |
I46.9 |
I47.0 |
I47.10 |
I47.11 |
I47.19 |
I47.20 |
I47.29 |
I47.9 |
I49.1 |
I49.2 |
I49.3 |
I49.01 |
I49.02 |
T82.6XXA |
T82.7XXA |
T82.110A |
T82.111A |
T82.118A |
T82.119A |
T82.120A |
T82.121A |
T82.128A |
T82.129A |
T82.190A |
T82.191A |
T82.198A |
T82.199A |
Z82.41 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
