NCD 20.4: Implantable Cardioverter Defibrillators (ICDs)
Medicare covers ICDs for both primary (no prior cardiac arrest) and secondary (post-cardiac arrest) prevention with specific criteria around LVEF, NYHA class, and prior MI timing.
What's covered
- Primary prevention: ischemic CM with LVEF ≤35%, NYHA II/III, ≥40 days post-MI
- Primary prevention: non-ischemic CM with LVEF ≤35%, NYHA II/III, ≥3 months on optimal medical therapy
- Secondary prevention: VF/sustained VT survivors
- CRT-D for select patients with QRS ≥130 ms
Coverage criteria
- LVEF measurement documented (echo, MUGA, cath)
- NYHA functional class documented
- On optimal medical therapy ≥3 months for non-ischemic
- ≥40 days post-MI for ischemic
- Shared decision-making documented (2018+)
Exclusions
- Within 40 days of MI for primary prevention (waiting period required)
- Within 90 days of revascularization (CABG or PCI)
- NYHA IV (unless awaiting transplant)
- Life expectancy <1 year
Common denial patterns
- Missing SDM documentation
- Wrong post-MI waiting period
- OMT duration not documented for non-ischemic CM
- LVEF measurement >30 days old
Appeal citation
NCD 20.4 (ICD), 2018 revision including SDM requirement. Cite LVEF, NYHA class, MI timing, and SDM note.
Frequently asked questions
What does Medicare NCD 20.4 cover?
Medicare covers ICDs for both primary (no prior cardiac arrest) and secondary (post-cardiac arrest) prevention with specific criteria around LVEF, NYHA class, and prior MI timing.
What are the coverage criteria?
LVEF measurement documented (echo, MUGA, cath); NYHA functional class documented; On optimal medical therapy ≥3 months for non-ischemic; ≥40 days post-MI for ischemic; Shared decision-making documented (2018+).
What is excluded?
Within 40 days of MI for primary prevention (waiting period required); Within 90 days of revascularization (CABG or PCI); NYHA IV (unless awaiting transplant); Life expectancy <1 year.
How do I cite this NCD in an appeal?
NCD 20.4 (ICD), 2018 revision including SDM requirement. Cite LVEF, NYHA class, MI timing, and SDM note.
Other Cardiology NCDs
Sources
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