Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 

The rules state that the following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
 
    Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
    Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
 
    Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia, 
    Asymptomatic first degree atrioventricular block, 
    Asymptomatic sinus bradycardia, 
    Asymptomatic sinoatrial block or asymptomatic sinus arrest, 
    Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia, 
    Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His 
Bundle (a component of the electrical conduction system of the heart), 
    Syncope of undetermined cause, 
    Bradycardia during sleep, 
    Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) 
without syncope or other symptoms of intermittent atrioventricular block, 
    Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker 
drug therapy, 
    Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 
    A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated 
with a reasonable likelihood that pacing needs will become prolonged. 
 
You can find these rules in National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber 
and Dual Chamber Permanent Cardiac Pacemakers (20.8.3). 
 
Effective for services performed on or after February 15, 2018, CMS has determined that the evidence is 
sufficient to conclude that the use of ICDs, (also referred to as defibrillators) is reasonable and necessary: 
 
    Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to 
Ventricular Fibrillation (VF). Patients must have demonstrated: 
        An episode of sustained VT, either spontaneous or induced by an Electrophysiology (EP) study, not 
associated with an acute Myocardial Infarction (MI) and not due to a transient or reversible cause; or 
        An episode of cardiac arrest due to VF, not due to a transient or reversible cause. 
 
    Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) = 0.30. Patients must not 
have: 
        New York Heart Association (NYHA) classification IV heart failure; or, 
        Had a Coronary Artery Bypass Graft (CABG), or Percutaneous Coronary Intervention (PCI) with 
angioplasty and/or stenting, within the past three (3) months; or, 
        Had an MI within the past 40 days; or, 
        Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
    For these patients identified in B2, a formal shared decision making encounter must occur between the 
patient and a physician (as defined in Section 1861(r)(1) of the Social Security Act (the Act))or qualified non-
physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined 
in ?1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. 
The shared decision-making encounter may occur at a separate visit. 
 
    Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or 
cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF = 35%. Additionally, patients 
must not have: 
 
        Had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months; or, 
        Had an MI within the past 40 days; or, 
        Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
 
    For these patients identified in B3, a formal shared decision making encounter must occur between the 
patient and a physician (as defined in Section 1861(r)(1) of the Act or qualified non-physician practitioner 
(meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in ?1861(aa)(5) of the 
Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision 
making encounter may occur at a separate visit. 
 
    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: 
 
        Had a CABG or PCI with angioplasty and/or stenting, within the past three (3) months; or, 
        Had an MI within the past 40 days; or, 
        Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
 
    For these patients identified in B4, a formal shared decision making encounter must occur between the 
patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner 
(meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in ?1861(aa)(5) of the 
Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision 
making encounter may occur at a separate visit. 
 
    Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias 
(sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy. 
 
    For these patients identified in B5, a formal shared decision making encounter must occur between the 
patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner 
(meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in ?1861(aa)(5) of the 
Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision 
making encounter may occur at a separate visit. 
    Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, 
Elective Replacement Indicator (ERI), or device/lead malfunction. 
 
For each of the six (6) covered indications above, the following additional criteria must also be met: 
 
    Patients must be clinically stable (e.g., not in shock, from any etiology); 
    LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic 
Resonance Imaging (MRI), or catheter angiography; 
    Patients must not have: 
        Significant, irreversible brain damage; or, 
        Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a 
likelihood of survival less than one (1) year; or, 
        Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate. 
Exceptions to waiting periods for patients that have had a CABG, or PCI with angioplasty and/or stenting, 
within the past three (3) months, or had an MI within the past 40 days: 
 
Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers, and who meet 
the criteria in this national coverage determination for an ICD, may receive the combined devices in one 
procedure, at the time the pacemaker is clinically indicated; 
 
Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the 
end of battery life, ERI, or device/lead malfunction. 
 
You can find this rule in National Coverage Determination (NCD) for Implantable Automatic Defibrillators 
(20.4). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.