When the indications for an ICD are not on the NCD we attach the Q0 modifier and send the report.
B. Policy: Medicare pays for implantable cardiac defibrillators according to certain indications and data
collection requirements. As explained in CR 3301, payment for services covered according to those
indications established through CRs 2880 and 2922 will be part of the capitated rates for MA plans
effective January 1, 2005, and for that reason, no longer paid FFS for beneficiaries under MA plans
effective for claims with dates of service on or after that date.
However, Medicare is expanding coverage for implantable defibrillators to include new indications,
effective January 27, 2005:
1. Patients 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%;
2. Patients with nonischemic dilated cardiomyopathy (NIDCM) > 9 months, NYHA Class II and III
heart failure, and measured LVEF ≤ 35%;
3. Patients who meet all current CMS coverage requirements for a cardiac resynchronization therapy
(CRT) device and have NYHA Class IV heart failure;
4. Patients with NIDCM > 3 months, NYHA Class II or III heart failure, and measured LVEF ≤ 35%.
Additional coverage requirements for each indication are specifically addressed in the National Coverage
Determinations Manual, section 20.4. One of these requirements includes participation in a data
collection system to determine safety and quality of care. Data collection is required for all the above
indications and for any other indication that represents the primary prevention of sudden cardiac death.
This primary prevention population is identifiable on claims through the absence of the following ICD-9
diagnosis codes:
? 427.1 ventricular tachycardia
? 427.41 ventricular fibrillation
? 427.42 ventricular flutter
? 427.5 cardiac arrest
? 427.9 cardiac dysrhythmia, unspecified