Implantable Automatic Defibrillators (NCD 20.4)

Implantable Automatic Defibrillators (NCD ) Page 1 of 8 UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Medicare Advantage Policy Guideline Implantable Automatic Defibrillators (NCD ) Guideline Number: Approval Date: November 10, 2021 Terms and Conditions Table of Contents Page Policy Summary .. 1 Applicable Codes .. 3 References .. 5 Guideline History/Revision Information .. 7 Purpose .. 7 Terms and Conditions .. 7 Policy Summary See Purpose Overview An Implantable cardioverter- defibrillator (ICD) (also referred to as Defibrillators ) is an electronic device designed to diagnose and treat life-threatening ventricular tachyarrhythmias.

4. Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF ≤ 35%, been on optimal medical therapy for at least three (3) months. Additionally, patients must not have:

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  Automatic, Implantable, Ischemic, Defibrillator, Cardiomyopathy, Implantable automatic defibrillators

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