CurrentConnectiCarePolicy MG.MM.DM.10

Automatic External Defibrillators

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This policy governs coverage of wearable and nonwearable automatic external defibrillators for ConnectiCare members with a DME benefit who are at high risk for sudden cardiac death. Coverage requires the applicable clinical criteria and supporting clinical documentation for prior authorization.

Policy Summary

PayerConnectiCare

PolicyAutomatic External Defibrillators

Policy CodePolicy MG.MM.DM.10

Change TypeMaterial clarification

Effective DateJun 12, 2026

Next Review DateNot scheduled

Key ActionSubmit clinical evidence showing that the member meets the applicable external-defibrillator criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

The policy clarified that the criterion for members who meet ICD requirements but have a temporary contraindication or are awaiting heart transplantation applies across all listed clinical indications.

The policy added a recommendation that members be reassessed at 3-month intervals for implantable cardioverter-defibrillator candidacy.

The policy content was transferred to an individual company-branded template and reorganized to improve communication of the clinical criteria.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentConnectiCarePolicy MG.MM.DM.10

Automatic External Defibrillators

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Policy Summary

PayerConnectiCare

PolicyAutomatic External Defibrillators

Policy CodePolicy MG.MM.DM.10

Change TypeMaterial clarification

Effective DateJun 12, 2026

Next Review DateNot scheduled

Key ActionSubmit clinical evidence showing that the member meets the applicable external-defibrillator criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

The policy added a recommendation that members be reassessed at 3-month intervals for implantable cardioverter-defibrillator candidacy.

The policy content was transferred to an individual company-branded template and reorganized to improve communication of the clinical criteria.

2Defibrillator categories

>30 secSustained VT threshold

≤35%LVEF threshold

≤30%LVEF threshold for prior-MI criterion

3 monthsICD candidacy reassessment

1 yearMinimum expected survival

Coverage Criteria

Wearable Defibrillator Coverage Criteria

Covered when the member has the DME benefit, is at high risk for sudden cardiac death, and the ordering physician is experienced in managing patients at risk for sudden cardiac death. At least one clinical indication must also be met.

General coverage requirements

Qualifying wearable-defibrillator indication
- Documented VF or sustained VT: Documented ventricular fibrillation episode or sustained ventricular tachycardia, either spontaneous or induced during an EP study; the dysrhythmia must not be due to a transient or reversible cause and must not occur during the first 48 hours of an MI.> 30 seconds for sustained VT
- Familial or inherited high-risk condition: Familial or inherited condition with a high risk of life-threatening ventricular tachycardia, such as long QT syndrome or hypertrophic cardiomyopathy.
- Prior MI or dilated cardiomyopathy with reduced LVEF: Documented prior myocardial infarction or dilated cardiomyopathy with a measured left ventricular ejection fraction at or below the policy threshold.LVEF ≤ 35%
- Temporary ICD contraindication or heart-transplant wait: Member satisfies requirements for an implantable cardioverter-defibrillator but has a temporary contraindication or is awaiting heart transplantation.
  This criterion applies across the clinical indications listed in the policy.
- ICD explantation required: A previously implanted implantable cardioverter-defibrillator requires explantation, such as because of an ICD system defect or infection caused by the ICD.

Nonwearable Defibrillator Coverage Criteria

Covered when both a qualifying clinical condition and an applicable implantation contraindication or ICD-explantation circumstance are present, in addition to the general DME and high-risk requirements.

General and nonwearable-defibrillator requirements

Criterion 1: qualifying clinical condition
- Cardiac arrest due to VF: Documented cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause.
- Sustained VT: Sustained ventricular tachycardia, either spontaneous or induced during an EP study, not associated with acute myocardial infarction and not due to a transient or reversible cause.> 30 seconds
- Familial or inherited high-risk condition: Familial or inherited condition with a high risk of life-threatening ventricular tachycardia, such as long QT syndrome or hypertrophic cardiomyopathy.

Coverage does not apply when a qualifying ventricular fibrillation episode or sustained ventricular tachycardia lasting more than 30 seconds is attributable to a transient or reversible cause. For wearable-defibrillator coverage, the event also must not occur during the first 48 hours of an acute myocardial infarction; for nonwearable-defibrillator coverage, sustained VT must not be associated with acute MI.

For the nonwearable-defibrillator criterion involving a documented prior MI and LVEF ≤30%, the member must not have cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm.

The applicable nonwearable-defibrillator criterion excludes members with a noncardiac disease—such as cancer, uremia, or liver failure—that is associated with a likelihood of survival of less than 1 year.

Medical Necessity

Wearable Defibrillator Medical Necessity

Medical necessity requires the general DME and high-risk requirements, followed by at least one qualifying clinical indication.

Wearable defibrillator medical necessity

At least one qualifying clinical indication
- Documented VF or sustained VT: Documented ventricular fibrillation episode or sustained ventricular tachycardia, spontaneous or induced during an EP study, not due to a transient or reversible cause and not occurring during the first 48 hours of an MI.> 30 seconds for sustained VT
- Familial or inherited high-risk condition: Familial or inherited condition with a high risk of life-threatening ventricular tachycardia, such as long QT syndrome or hypertrophic cardiomyopathy.

Coding and Clinical Thresholds

Procedure Codesmixed

93292	Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system.
93745	Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events.
K0606	Automatic external defibrillator with integrated electrocardiogram analysis, garment type.
K0607	Replacement battery for automated external defibrillator, garment type only, each.
K0608	Replacement garment for use with automated external defibrillator, each.
K0609	Replacement electrodes for use with automated external defibrillator, garment type only, each.
E0617	External defibrillator with integrated electrocardiogram analysis.

Diagnosis CodesICD-10

A18.84	Tuberculosis of heart.
I21.A1	Myocardial infarction type 2.
I21.A9	Other myocardial infarction type.
I21.01	ST elevation (STEMI) myocardial infarction involving left main coronary artery.
I21.02	ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery.
I21.09	ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall.
I21.11	ST elevation (STEMI) myocardial infarction involving right coronary artery.
I21.19	ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall.
I21.21	ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery.
I21.29	ST elevation (STEMI) myocardial infarction involving other sites.

1–10 of 78

1/8

Sustained ventricular tachycardia

Threshold> 30 seconds

TermSustained ventricular tachycardia

Qualifying settingMay be spontaneous or induced during an EP study

Left ventricular ejection fraction

Threshold≤35%

MeasurementLeft ventricular ejection fraction

Applicable conditionsPrior myocardial infarction or dilated cardiomyopathy; also used with ischemic or nonischemic dilated cardiomyopathy and heart failure criteria

Provider Actions and Decision Risks

Prior Authorization

Prior Authorization Required

Requests for an automatic external defibrillator are subject to utilization-management review. The treating physician or primary care provider must submit clinical evidence before ConnectiCare can properly review the request for prior authorization.

Submit the request through the applicable prior-authorization process.
Coverage is limited to members with the DME benefit and a qualifying high risk of sudden cardiac death.

Documentation Required

Submit Clinical Evidence Supporting Eligibility

Submit documentation demonstrating that the member meets the applicable wearable or nonwearable defibrillator criteria. Medical necessity does not by itself guarantee payment; the member’s benefit plan and any applicable coverage limitations govern.

Document the qualifying cardiac condition, test results, and relevant clinical history.

Documentation Requirements

Documentation Required

Submit complete clinical documentation

The treating physician or primary care provider must provide documentation that the member meets the applicable external-defibrillator criteria.

Qualifying diagnosis and documented rhythm or cardiac event.
Measured LVEF and MI history and timing.
EP-study findings and timing when applicable.
Heart-failure classification.
Implantation contraindication or need for ICD explantation.
Absence of applicable exclusions.

Documentation Required

Document ordering physician experience

The ordering physician should be experienced in managing patients at risk for sudden cardiac death.

Background

Automatic external defibrillators provide external defibrillation support for members at elevated risk of sudden cardiac death from ventricular arrhythmias or other qualifying cardiac conditions. Wearable defibrillators may provide temporary protection when an implantable cardioverter-defibrillator is contraindicated, deferred, or being considered, while nonwearable defibrillators are covered only under specified high-risk clinical circumstances. Eligibility is determined using documented arrhythmia history, myocardial infarction status and timing, left ventricular ejection fraction, cardiomyopathy, heart-failure classification, electrophysiologic-study findings, and implantation status.

Definitions

AbbreviationEP

Full termElectrophysiologic study

Policy useMay be the setting in which qualifying ventricular tachycardia or ventricular fibrillation is induced

LVEF

AbbreviationLVEF

Full termLeft ventricular ejection fraction

Policy useMeasured to assess eligibility under multiple external-defibrillator criteria

Policy Summary

PayerConnectiCare

PolicyAutomatic External Defibrillators

Policy CodePolicy MG.MM.DM.10

Change TypeMaterial clarification

Effective DateJun 12, 2026

Next Review DateNot scheduled

Key ActionSubmit clinical evidence showing that the member meets the applicable external-defibrillator criteria for prior authorization review.

SourceLink

On This Page

Coronary artery disease with prior MI and inducible arrhythmia: Coronary artery disease with documented prior myocardial infarction, measured LVEF at or below the policy threshold, and inducible sustained ventricular tachycardia or ventricular fibrillation during an EP study.LVEF ≤ 35%; MI > 4 weeks before prescription; EP test > 4 weeks after qualifying MI

Both timing requirements must be met.

Prior MI with severely reduced LVEF: Documented prior myocardial infarction and measured LVEF at or below the policy threshold, with none of the listed exclusions: cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; CABG or PTCA within the past 3 months; enzyme-positive MI within 40 days; clinical symptoms or findings indicating candidacy for coronary revascularization; irreversible brain damage from pre-existing cerebral disease; or noncardiac disease associated with a likelihood of survival under 1 year.LVEF ≤ 30%; CABG/PTCA not within past 3 months; enzyme-positive MI not within 40 days; expected survival must not be less than 1 year

Ischemic dilated cardiomyopathy with heart failure: Ischemic dilated cardiomyopathy, documented myocardial infarction, NYHA Class II or III heart failure, and measured LVEF at or below the policy threshold.LVEF ≤ 35%

Nonischemic dilated cardiomyopathy with heart failure: Nonischemic dilated cardiomyopathy for longer than the specified duration, NYHA Class II or III heart failure, and measured LVEF at or below the policy threshold.Cardiomyopathy > 3 months; LVEF ≤ 35%

Prior qualifying criterion with NYHA Class IV heart failure: One of the previous qualifying criteria in this section and NYHA Class IV heart failure.

Criterion 2: implantation or ICD circumstance

Implantation contraindicated: Implantation surgery is contraindicated.
ICD explantation required: A previously implanted implantable cardioverter-defibrillator requires explantation, such as because of an ICD system defect or infection caused by the ICD.

Prior MI or dilated cardiomyopathy with reduced LVEF: Documented prior myocardial infarction or dilated cardiomyopathy with measured LVEF at or below the policy threshold.LVEF ≤ 35%

Temporary ICD contraindication or heart-transplant wait: Member satisfies requirements for an implantable cardioverter-defibrillator but has a temporary contraindication or is awaiting heart transplantation.

ICD explantation required: A previously implanted implantable cardioverter-defibrillator requires explantation, such as because of an ICD system defect or infection caused by the ICD.

Nonwearable Defibrillator Medical Necessity

Medical necessity requires both a qualifying clinical condition and an implantation contraindication or qualifying ICD-explantation circumstance.

Nonwearable defibrillator medical necessity

Qualifying clinical condition
- Cardiac arrest due to VF: Documented cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause.
- Sustained VT: Sustained ventricular tachycardia, spontaneous or induced during an EP study, not associated with acute myocardial infarction and not due to a transient or reversible cause.> 30 seconds
- Familial or inherited high-risk condition: Familial or inherited condition with a high risk of life-threatening ventricular tachycardia, such as long QT syndrome or hypertrophic cardiomyopathy.
- Coronary artery disease with prior MI and inducible arrhythmia: Coronary artery disease with documented prior myocardial infarction, measured LVEF at or below the policy threshold, and inducible sustained ventricular tachycardia or ventricular fibrillation during an EP study.LVEF ≤ 35%; MI > 4 weeks before prescription; EP test > 4 weeks after qualifying MI
- Prior MI with severely reduced LVEF: Documented prior myocardial infarction and measured LVEF at or below the policy threshold, with all listed exclusions absent.LVEF ≤ 30%; CABG/PTCA not within past 3 months; enzyme-positive MI not within 40 days; expected survival must not be less than 1 year
  Exclusions include cardiogenic shock or symptomatic hypotension in a stable baseline rhythm, findings indicating revascularization candidacy, and irreversible brain damage from pre-existing cerebral disease.
- Ischemic dilated cardiomyopathy with heart failure: Ischemic dilated cardiomyopathy, documented myocardial infarction, NYHA Class II or III heart failure, and measured LVEF at or below the policy threshold.LVEF ≤ 35%
- Nonischemic dilated cardiomyopathy with heart failure: Nonischemic dilated cardiomyopathy for longer than the specified duration, NYHA Class II or III heart failure, and measured LVEF at or below the policy threshold.Cardiomyopathy > 3 months; LVEF ≤ 35%
- Prior qualifying criterion with NYHA Class IV heart failure: One of the previous qualifying criteria in this section and NYHA Class IV heart failure.
Implantation or ICD circumstance
- Implantation contraindicated: Implantation surgery is contraindicated.
- ICD explantation required: A previously implanted implantable cardioverter-defibrillator requires explantation, such as because of an ICD system defect or infection caused by the ICD.

Prior-myocardial-infarction LVEF

Threshold≤30%

MeasurementLeft ventricular ejection fraction

Applicable conditionDocumented prior myocardial infarction criterion

Qualifying myocardial infarction timing

Timing requirement> 4 weeks before the external defibrillator prescription

EventQualifying myocardial infarction

Applicable criterionCoronary artery disease with prior myocardial infarction, LVEF ≤35%, and inducible sustained VT or VF during an EP study

EP test timing

Timing requirement> 4 weeks after the qualifying myocardial infarction

TestElectrophysiologic test

Applicable findingInducible sustained ventricular tachycardia or ventricular fibrillation

Recent CABG or PTCA

Timing restrictionMust not be within the past 3 months

ProceduresCoronary artery bypass graft or percutaneous transluminal coronary angioplasty

Applicable criterionPrior myocardial infarction with LVEF ≤30%

Enzyme-positive myocardial infarction

Timing restrictionMust not be within 40 days

EventEnzyme-positive myocardial infarction

Applicable criterionDocumented prior myocardial infarction with LVEF ≤30%

Nonischemic dilated cardiomyopathy

Duration requirement> 3 months

ConditionNonischemic dilated cardiomyopathy

Additional clinical requirementsNYHA Class II or III heart failure and measured LVEF ≤35%

Expected survival with noncardiac disease

Minimum expected survivalMust not be less than 1 year

Disease categoryDisease other than cardiac disease, including cancer, uremia, or liver failure

Coverage impactSurvival under 1 year is an exclusion for the applicable nonwearable-defibrillator criterion

For nonwearable devices, document both a qualifying condition and either contraindication to implantation surgery or a qualifying prior ICD explantation.

For applicable ischemic criteria, include MI timing, EP-study results, LVEF, and heart-failure classification.

Note

Ordering Physician Experience

The ordering physician should be experienced in managing patients at risk for sudden cardiac death.

Ensure the ordering clinician’s experience is appropriate to the member’s SCD-risk condition and requested device.

Denial Risk

Failure to Meet Coverage Criteria

Coverage may be denied when the member does not have the applicable DME benefit, is not at high risk for sudden cardiac death, or does not meet the policy’s clinical criteria. A medically necessary service may still be excluded or unpaid under the member’s benefit plan.

Verify that the member’s plan includes the DME benefit and does not exclude the requested supply.
Document a qualifying condition under the wearable or nonwearable criteria.
Requests lacking evidence that all applicable criteria are met may not be approved.
Medicare coverage may also be subject to applicable CMS NCDs, LCDs, or other coverage statements.

Denial Risk

Reversible Cause or Timing Exclusion

Ventricular fibrillation or sustained ventricular tachycardia must not be attributable to a transient or reversible cause. Timing-related exclusions also apply to events occurring during the acute MI period or before required post-MI intervals.

For wearable criteria, a documented VF episode or sustained VT (> 30 seconds) may not occur during the first 48 hours of an MI or result from a transient or reversible cause.
For nonwearable criteria, cardiac arrest due to VF must not have a transient or reversible cause; sustained VT must not be associated with acute MI or a transient or reversible cause.
For the coronary artery disease criterion, the qualifying MI and EP study must each have occurred more than 4 weeks before the external-defibrillator prescription as specified.

Denial Risk

Nonwearable Defibrillator Exclusions

A nonwearable defibrillator requires a qualifying clinical condition plus either contraindication to implantation surgery or a qualifying prior ICD explantation. Document the applicable exception; a qualifying condition alone is insufficient.

Document one qualifying condition, such as cardiac arrest from VF, sustained VT, a high-risk familial or inherited condition, qualifying ischemic or dilated cardiomyopathy, or the specified prior-MI/LVEF criteria.
Document that implantation surgery is contraindicated, or that a previously implanted ICD requires explantation because of a system defect or infection caused by the ICD.
For prior MI with LVEF ≤ 30%, document absence of the listed exclusions, including cardiogenic shock or symptomatic hypotension, recent CABG/PTCA, enzyme-positive MI within 40 days, revascularization candidacy, irreversible pre-existing cerebral injury, or noncardiac disease with expected survival under 1 year.

Documentation Required

Insufficient Documentation or Benefit Limitation

Requests may not be reviewable when the clinical evidence needed to apply the policy is missing, or when the member’s benefit does not cover the requested DME. Confirm benefit eligibility and submit complete supporting records.

Include the clinical documentation needed to establish the applicable criteria and exclude reversible or timing-related causes.
Confirm the member’s applicable DME benefit before ordering.
If the benefit plan conflicts with the guideline, the benefit plan governs.

AbbreviationMI

Full termMyocardial infarction

Policy useUsed in criteria addressing prior myocardial infarction and event timing

SCD

AbbreviationSCD

Full termSudden cardiac death

Policy contextThe policy addresses external defibrillator coverage for members at high risk for sudden cardiac death

AbbreviationVF

Full termVentricular fibrillation

Policy useA documented VF episode or cardiac arrest due to VF may qualify when applicable exclusions are absent

AbbreviationVT

Full termVentricular tachycardia

Policy useSustained VT qualifies at greater than 30 seconds when applicable criteria and exclusions are satisfied