Wearable Cardiac Defibrillators (WCD) Coverage Criteria
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Criteria and coverage policy for wearable (vest-like) external cardiac defibrillators and related AED devices for adult members, including prior authorization information and applicable billing codes for Moda Health.
No material clinical or coverage changes in this revision.
Coverage Criteria for Wearable Cardiac Defibrillators
Initial coverage criteria (short-term WCD use)
Covered when ALL of the following are met:
Primary coverage criteria
EP-confirmed indications (one or more must be present)
- Hereditary high-risk condition: Hereditary condition with high‑risk incidence of ventricular tachyarrhythmias (e.g., long QT syndrome, hypertrophic cardiomyopathy).
- Documented ventricular arrhythmia: Documented ventricular fibrillation (VF) or sustained (≥30 seconds) ventricular tachycardia (VT) that is not due to a transient/reversible cause and does not occur during the first 48 hours of an acute myocardial infarction; may be spontaneous or induced during EP study.
- Temporary bridge to transplant or ICD: WCD used temporarily until the member receives a heart transplant or an implantable ICD implantation.
- Not candidate for ICD: Member is not a suitable candidate for an implantable cardiac defibrillator (ICD).
- Post-MI bridge within 40 days: WCD used post‑myocardial infarction as a bridge during the first 40 days post‑event while awaiting ICD when there is either (1) ventricular tachycardia or ventricular fibrillation in the first 48 hours post‑infarct, or (2) left ventricular ejection fraction (LVEF) ≤ 35%.<= 35% for LVEF
- Refusal of ICD: Member refuses ICD placement.
- Temporary contraindication to ICD: Member has a systemic infection or other temporary condition that precludes ICD implantation.
Non-wearable automatic external defibrillators (AEDs) for home use in adults (age 18 and older) are considered investigational and are not covered by this policy.
Home use non-wearable AEDs for adults are considered investigational due to a lack of peer-reviewed evidence demonstrating clinical benefit. The policy notes there are few published studies reporting clinical outcomes for AED use in the home by laypersons and no studies evaluating whether home AED use reduces mortality compared with alternatives such as implantable cardioverter-defibrillators (ICDs) or emergency responder treatment. For Medicare-specific guidance, refer to Noridian LCD L33690.
Applicable Billing and Diagnosis Codes
| 93292 | Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional; wearable defibrillator system Initial set-up and programming by a physician or other qualified health care professional |
| 93745 | Wearable defibrillator system Initial setup 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 | Wearable, automatic, EXTERNAL DEFIBRILLATORs with integrated electrocardiogram analysis |
| K0607 | Replacement battery for automated external defibrillator, garment type only |
| K0608 | Replacement garment for use with automated external defibrillator |
| K0609 | Replacement electrodes for use with automated external defibrillator, garment type only |
| E0617 | Non wearable automatic EXTERNAL DEFIBRILLATORS with integrated electrocardiogram capability |
| B57.0 | Acute Chagas' disease with heart involvement |
| B57.2 | Chagas' disease (chronic) with heart involvement |
| D86.9 | Sarcoidosis, unspecified |
| I25.3 | Aneurysm of heart |
| I25.5 | Ischemic cardiomyopathy |
| I25.89 | Other forms of chronic ischemic heart disease |
| I25.9 | Chronic ischemic heart disease, unspecified |
| I40.0 | Infective myocarditis |
| I40.1 | Isolated myocarditis |
| I42.1 | Obstructive hypertrophic cardiomyopathy |
Prior Authorization, Documentation, and Denial Triggers
Prior authorization required; coverage when all criteria met
Prior authorization is required. Submit the required clinical documentation with the prior authorization request; Moda Health will cover FDA‑approved wearable cardiac defibrillators (WCDs) when ALL policy criteria are met. WCDs are typically rented monthly with initial approval for up to 3 months, and continued coverage beyond 3 months requires a new request with additional clinical documentation.
No step therapy specified
There are no step therapy requirements for WCDs under this policy.
Required clinical documentation to submit with prior authorization
Include the treating physician’s history and physical, results of electrophysiology (EP) studies, documentation of any contraindication to an implantable cardiac defibrillator (ICD), and the anticipated duration of WCD use with the prior authorization request.
- History and physical from the treating physician
- Results of electrophysiology studies
- Documentation of patient contraindication to ICD (if applicable)
- Anticipated length of time that WCD will be used
Denial risk when required criteria or documentation are missing
Requests may be denied if ALL coverage criteria are not met — common triggers include absence of a face‑to‑face exam within 6 months, failure to meet ICD eligibility, member age under 18, missing EP study results when required, or requested duration exceeding the allowed initial 3 months without new documentation.
- No face-to-face exam within 6 months prior to request
- Does not meet implantable cardiac defibrillator (ICD) eligibility
- Member is under 18 years of age
- Missing electrophysiology study results when such testing is required
- Requested WCD duration exceeds 3 months without submission of new clinical documentation
Background
A wearable cardiac defibrillator (WCD) is a vest-like external device worn nearly continuously (except for bathing) that monitors cardiac rhythm and can detect life‑threatening ventricular tachyarrhythmias. When such arrhythmias are detected, the WCD can deliver an electrical shock to terminate ventricular tachycardia or fibrillation. WCDs are intended primarily for short-term protection—for example, as a bridge until implantable cardioverter-defibrillator (ICD) implantation, heart transplant, or resolution of a temporary contraindication to ICD placement. When approved, WCDs are typically rented monthly.
Definitions
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