Coverage Criteria for Nonwearable Automatic Defibrillators

by  Find-A-Code
April 19th, 2018

According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:

  1. The beneficiary has one of the following conditions (1-8):
    1. A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause
    2. A sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia, either spontaneous or induced during an electrophysiologic (EP) study, not associated with acute myocardial infarction, and not due to a transient or reversible cause
    3. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy
    4. Coronary artery disease with a documented prior myocardial infarction with a measured left ventricular ejection fraction less than or equal to 0.35, and inducible, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during an EP study. To meet this criterion;
      1. The myocardial infarction must have occurred more than 4 weeks prior to the external defibrillator prescription; and, 
      2. The EP test must have been performed more than 4 weeks after the qualifying myocardial infarction.
    5. Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Beneficiaries must not have:
      1. Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; or,
      2. Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; or,
      3. Had an enzyme-positive MI within past month; or,
      4. Clinical symptoms or findings that would make them a candidate for coronary revascularization; or,
      5. Irreversible brain damage from preexisting cerebral disease; or,
      6. Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than one year.
    6. Beneficiaries with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI), New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) ≤ 35%.
    7. Beneficiaries with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%
    8. Beneficiaries who meet criteria (1-7) and have NYHA Class IV heart failure
  2. Implantation surgery is contraindicated

  3. A previously implanted defibrillator now requires explantation


Coverage Criteria for Nonwearable Automatic Defibrillators. (2018, April 19). Find-A-Code Articles. Retrieved from

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