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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 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: 
 
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. 
 
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. 
 
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 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. 
    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. 
    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. 
    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; 
 
You can find this information in the National Coverage Determination (NCD) Implantable Cardioverter 
Defibrillators (ICDs) 20.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.