Latest Review Date:  May 2024

Category: DME                                                                

POLICY:

Effective for dates of service on and after February 15, 2024:

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage in individuals who meet both of the following criteria:

• meet the criteria for an implantable cardioverter-defibrillator (established by medical policy No.168 Cardioverter Defibrillators: Implantable); AND
• require interim treatment BUT cannot be treated with an implantable cardioverter defibrillator;

And must also have one of the following criteria:

• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and has been scheduled for an ICD placement; OR
• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and had an ICD removed and has been rescheduled for placement of another ICD once the contraindication is treated.

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage as a bridge to left ventricular improvement or possible ICD implantation for the following indications:

• LVEF is less than or equal to 35%

AND

• Have had a recent diagnosis of nonischemic cardiomyopathy and within the 3 month waiting period after starting guideline directed medical therapy; OR 
• Have had a recent myocardial infarction and within the 40 day period that an ICD implantation is not indicated or is deferred. A wearable cardioverter-defibrillator may be covered for up to three months in this situation; OR
• Awaiting ICD placement following a CABG or PCI with angioplasty and/or stenting within the past 3 months (with or without MI).

In the absence of eligible criteria as mentioned above, the use of WCDs is considered investigational for the following indications when they are the sole indication for a wearable cardioverter defibrillator:

• Individuals post coronary artery bypass graft surgery
• Women with peripartum cardiomyopathy
• High-risk patients awaiting a heart transplant

Automatic External Defibrillators (AEDs) for home use may be considered medically necessary in patients who meet criteria for implantation of ICD, but cannot be treated with an implantable cardioverter defibrillator or have a contraindication to ICD placement.  Contraindications for ICD are the same as described in the previous paragraph under the wearable cardioverter-defibrillator.

An FDA approved pediatric Automatic External Defibrillators (AEDs) for home use may be considered medically necessary for children who meet ALL of the following criteria:

• Child is 1-8 years of age; AND
• Child weighs less than 55 pounds; AND
• Child is at risk for sudden cardiac death (e.g. long QT syndrome, cardiomyopathy).

The use of WCDs is considered investigational for all other indications.

Effective for dates of service July 16, 2022 through February 14, 2024:

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage in individuals who meet both of the following criteria:

• meet the criteria for an implantable cardioverter-defibrillator  (established by medical policy No.168 Cardioverter Defibrillators: Implantable); AND
• require interim treatment BUT cannot be treated with an implantable cardioverter defibrillator;

And must also have one of the following criteria:

• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and has been scheduled for an ICD placement; OR
• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and had an ICD removed and has been rescheduled for placement of another ICD once the contraindication is treated.

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage as a bridge to left ventricular improvement or possible ICD implantation for the following indications:

• LVEF is less than or equal to 35%

AND

• Have had a recent diagnosis of nonischemic cardiomyopathy and within the 3 month waiting period after starting guideline directed medical therapy; OR 
• Have had a recent myocardial infarction and within the 40 day period that an ICD implantation is not indicated or is deferred. A wearable cardioverter-defibrillator may be covered for up to three months in this situation; OR
• Awaiting ICD placement following a CABG or PCI with angioplasty and/or stenting within the past 3 months (with or without MI).

In the absence of eligible criteria as mentioned above, the use of WCDs is considered investigational for the following indications when they are the sole indication for a wearable cardioverter defibrillator:

• Individuals post coronary artery bypass graft surgery
• Women with peripartum cardiomyopathy
• High-risk patients awaiting a heart transplant

Automatic External Defibrillators (AEDs) for home use may be considered medically necessary in patients who meet criteria for implantation of ICD, but cannot be treated with an implantable cardioverter defibrillator or have a contraindication to ICD placement.  Contraindications for ICD are the same as described in the previous paragraph under the wearable cardioverter-defibrillator.

The use of WCDs is considered investigational for all other indications.

Effective for dates of service March 1, 2019 – July 15, 2022:

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage in individuals who meet both of the following criteria:

• meet the criteria for an implantable cardioverter-defibrillator  (established by medical policy No.168 Cardioverter Defibrillators: Implantable); AND
• require interim treatment BUT cannot be treated with an implantable cardioverter defibrillator;

And must also have one of the following criteria:

• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and has been scheduled for an ICD placement; OR
• Have a temporary contraindication to receiving an ICD such as a systemic infection, at the current time and had an ICD removed and has been rescheduled for placement of another ICD once the contraindication is treated.

The wearable cardioverter-defibrillator for the prevention of sudden cardiac death may be considered medically necessary for coverage as a bridge to left ventricular improvement or possible ICD implantation for the following indications:

• LVEF is less than or equal to 35%; AND
• Have had a recent diagnosis of nonischemic dilated or hypertrophic cardiomyopathy and within the 3 month waiting period after starting guideline directed medical therapy; OR 
• Have had a recent myocardial infarction and within the 40 day period that an ICD implantation is not indicated or is deferred. This will be considered for up to 3 months. 

In the absence of eligible criteria as mentioned above, the use of WCDs is considered investigational for the following indications when they are the sole indication for a wearable cardioverter defibrillator:

• Individuals post coronary artery bypass graft surgery
• Women with peripartum cardiomyopathy
• High-risk patients awaiting a heart transplant

Automatic External Defibrillators (AEDs) for home use may be considered medically necessary in patients who meet criteria for implantation of ICD, but cannot be treated with an implantable cardioverter defibrillator or have a contraindication to ICD placement.  Contraindications for ICD are the same as described in the previous paragraph under the wearable cardioverter-defibrillator.

The use of WCDs is considered investigational for all other indications.

DESCRIPTION OF PROCEDURE:

A wearable cardioverter-defibrillator (WCD) is a temporary, external device that is an alternative to an implantable cardioverter-defibrillator (ICD). It is primarily intended for temporary conditions for which an implantable device is contraindicated, or for a period of time during which the need for a permanent implantable device is uncertain.

An automated external defibrillator (AED) is a portable device that is not continuously worn.  It can deliver electric shocks through the chest when it is connected and detects an abnormal heart rhythm.

Sudden Cardiac Arrest

Sudden cardiac arrest (SCA) is the most common cause of death in patients with coronary artery disease.

Treatment

The ICD has proven effective in reducing mortality for survivors of SCA and for patients with documented malignant ventricular arrhythmias. More recently, the use of ICDs has been broadened by studies reporting a reduction in mortality for patients at risk for ventricular arrhythmias, such as patients with prior myocardial infarction (MI) and reduced ejection fraction.

ICDs consist of implantable leads, which are placed percutaneously in the heart, that are connected to a pulse generator implanted beneath the skin of the chest or abdomen. ICD placement is a minor surgical procedure. Potential adverse events of ICD placement are bleeding, infection, pneumothorax, and delivery of unnecessary counter shocks. See Policy No.168 “Cardioverter Defibrillators: Implantable” for further information on ICDs.

The WCD is an external device that is intended to perform the same tasks as an ICD, without requiring invasive procedures. It consists of a vest that is worn continuously underneath the patient's clothing. Part of this vest is the “electrode belt” that contains the cardiac-monitoring electrodes and the therapy electrodes that deliver a counter shock. The vest is connected to a monitor with a battery pack and alarm module that is worn on the patient’s belt. The monitor contains the electronics that interpret the cardiac rhythm and determines when a counter shock is necessary. The alarm module alerts the patient to certain conditions by lights or voice messages, during which time a conscious patient can abort or delay the shock.

An AED is also an external device that delivers shocks to the heart without requiring invasive procedures.  It is an automated device that uses voice prompts, lights, and texts to instruct the rescuer steps to take based on the heart rhythm the machine detects.  Once the pads are placed on the individual’s chest, the AED will analyze the heart rhythm and deliver a shock if needed.  It will continue to instruct the rescuer steps to take such as initiating CPR or to stand back so another shock can be given.

KEY POINTS:

The most recent literature update was performed through March 27, 2024.

Summary of Evidence

Overview of Wearable Cardioverter Defibrillator (WCD) Versus Implantable Cardioverter Defibrillator (ICD) 

One randomized controlled trial (RCT) has compared WCD with usual guideline-based care and found no significant benefit to WCD over usual care. No studies have directly compared the performance of a WCD with a permanent ICD. One small study in an electrophysiology lab demonstrated that the WCD can correctly identify and terminate most induced ventricular arrhythmias. Similarly, a study of the ASSURE WCD in patients with cardiomyopathy found that the WCD detected all events recorded by an ICD with few false-positive shock alarms in a 30-day period. A cohort study of WCD use estimated that the percentage of successful resuscitations was approximately 70%. Multiple studies have demonstrated suboptimal adherence. Device failures were largely attributed to incorrect device use and/or nonadherence. A more recent registry study has reported a high compliance rate, although these results may be biased by self-selection. Collectively, this evidence indicates that the WCD can successfully detect and terminate arrhythmias in at least some patients but that overall performance in clinical practice might be inferior to a permanent ICD.

Temporary Contraindications

For individuals who have a temporary contraindication for an implantable cardioverter defibrillator (ICD) who receive a wearable cardioverter defibrillator (WCD), the evidence includes prospective cohort studies and a technology assessment that assessed ICD devices, given the absence of evidence on WCD devices. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related morbidity. A small number of patients meet established criteria for an ICD but have a transient contraindication for an implantable device, most commonly an infectious process. The available data establish that the WCD device can detect lethal arrhythmias and successfully deliver a countershock in most cases. In patients scheduled for ICD placement, the WCD will improve outcomes as an interim treatment. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Immediate Post Myocardial Infarction

For individuals who are in the immediate post myocardial infarction period who receive a WCD, the evidence includes a randomized controlled trial (RCT) comparing WCD with guideline-based therapy, 2 cohort studies, and a systematic review. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related morbidity. The RCT reported did not lead to a significantly lower rate of arrhythmic death during the first 90 days; however, there was successful conversion in 20 participants in the device group who received an appropriate shock. A cohort study of 8453 patients showed that 252 shocks successfully terminated ventricular fibrillation or ventricular tachycardia (82% success rate). The evidence is sufficient to determine the effects of the technology on health outcomes.

Newly Diagnosed Nonischemic Cardiomyopathy

For individuals with newly diagnosed nonischemic cardiomyopathy, the evidence includes an RCT for ICD and multiple retrospective analyses of registry data for WCD. Relevant outcomes are OS, morbid events, functional outcomes, and treatment-related morbidity. Results of the RCT did not show a statistical significant reduction in all-cause mortality; however, there was a significant reduction in sudden cardiac death in the ICD arm. Overall, retrospective studies have shown low incidences of inappropriate shocks and that WCDs could be an effective treatment in preventing SCD. Because patients with newly diagnosed NICM and LVEF ≤35% show an elevated risk of ventricular arrhythmias during initiation and optimization of heart failure therapy, the evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Post-Coronary Artery Bypass Graft Surgery at High Risk for Lethal Arrhythmias

For individuals who are post coronary artery bypass graft surgery and at high risk for lethal arrhythmias, the evidence includes an RCT for ICD and a registry study. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment–related morbidity. For high-risk post coronary artery bypass graft patients, an RCT reported no difference in overall survival associated with early ICD placement. The registry study found survival benefits with WCD, but had limited interpretation of data. However, because individuals with an LVEF ≤ 35% are at a higher risk for mortality after PCI or CABG, it is reasonable for this population to have a WCD. The evidence is sufficient to determine that the technology results in an improvement in the net health outcomes.

Awaiting Heart Transplantation at High Risk for Lethal Arrhythmias

For individuals who are awaiting heart transplantation and are at high risk for lethal arrhythmias, the evidence includes analyses of subsets of patients from the manufacturer registry, a subset from a prospective cohort study, and a case series. Relevant outcomes are OS, morbid events, functional outcomes, and treatment-related morbidity. These studies do not provide sufficient evidence to determine whether a WCD is of benefit compared with usual care. The evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Peripartum Cardiomyopathy

For individuals who have peripartum cardiomyopathy, the evidence includes a retrospective registry data analysis and a small cohort study. Relevant outcomes are OS, morbid events, functional outcomes, and treatment-related morbidity. The registry study revealed that no shocks were delivered during use over an average of 124 days. The cohort study identified 4 episodes of appropriate electric shock over 133 days. The evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Automated External Defibrillator

For adults who have a risk of SCD and meet criteria for implantation of ICD, but cannot be treated with an implantable cardioverter defibrillator, or have a contraindication to ICD placement and need an AED, the evidence consists of retrospective reviews, a randomized controlled trial, and a systematic review. A RCT stated the ratio of survivors to hospital discharge was higher in the group that had individuals trained in CPR plus the use of the AED compared to the group who performed CPR only. Multiple studies have established that early defibrillation improves survival after a cardiac arrest. The evidence is sufficient to determine that the technology results in an improvement in the net health outcomes.

For children who are one to 8 years of age, weigh less than 55 pounds and do not meet ICD criteria but need an AED, the evidence consists of observational studies and systematic reviews. Studies have shown that AEDs are accurate in detecting arrhythmias in children and have high sensitivity in detecting ventricular fibrillation and high sensitivity for identifying non-shockable rhythms.  According to the American Heart Association, children treated with an AED had a survival rate of 29.1% compared to 23.7% in those who were not treated with an AED. The evidence is sufficient to determine that the technology results in an improvement in the net health outcomes.

Practice Guidelines and Position Statements

American Heart Association et al

In 2018, the American Heart Association (AHA), the American College of Cardiology and the Heart Rhythm Society published a guideline on the management of patients with ventricular arrhythmias and prevention of sudden cardiac death. The guidelines note that "the patients listed in this recommendation are represented in clinical series and registries that demonstrate the safety and effectiveness of the wearable cardioverter defibrillator. Patients with recent MI, newly diagnosed NICM, recent revascularization, myocarditis, and secondary cardiomyopathy are at increased risk of VT/SCA (ventricular tachycardia/sudden cardiac arrest). However, the wearable cardioverter-defibrillator is of unproven benefit in these settings, in part because the clinical situation may improve with therapy and time." The specific recommendations are summarized in Table 1. Class IIa is moderate recommendation, and class IIb is a weak recommendation, and class III is a moderate recommendation for no benefit or a strong recommendation for harm.

 

Table 1. Guidelines for WCD Therapy

Recommendation	COR	LOE
"In patients with an ICD and a history of SCA or sustained VA in whom removal of the ICD is required (as with infection, the wearable cardioverter-defibrillator is reasonable for the prevention of SCD."	IIa	B-NR
"In patients at an increased risk of SCD but who are not ineligible for an ICD, such as awaiting cardiac transplant, having an LVEF of 35% or less and are within 40 days from an MI, or have newly diagnosed, NICM, revascularization within the past 90days, myocarditis or secondary cardiomyopathy or a systemic infection, the wearable cardioverter-defibrillator may be reasonable."	IIb	B-NR

B-NR: Level B - nonrandomized; COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; LVEF: left ventricular ejection fraction; MI: myocardial infarction; NICM: nonischemic cardiomyopathy; SCD: sudden cardiac death; WCD: wearable cardioverter defibrillator.

In 2016, the American Heart Association (AHA) published a scientific advisory on the wearable cardioverter defibrillator (WCD). AHA stated that “because there is a paucity of prospective data supporting the use of the WCD, particularly in the absence of any published, randomized, clinical trials, the recommendations provided in this advisory are not intended to be prescriptive or to suggest an evidence-based approach to the management of patients with FDA-approved indications for use.” The specific recommendations are summarized in Table 2.

Table 2: Guidelines for WCD Therapy

Recommendation	COR	LOE
“Use of WCDs is reasonable when there is a clear indication for an implanted/permanent device accompanied by a transient contraindication or interruption in ICD care such as infection.”	IIa	C
“Use of WCDs is reasonable as a bridge to more definitive therapy such as cardiac transplantation”	IIa	C
“Use of WCDs may be reasonable when there is concern about a heightened risk of SCD that may resolve over time or with treatment of left ventricular dysfunction/ for example, in ischemic heart disease with recent revascularization, newly diagnosed nonischemic dilated cardiomyopathy in patients starting guideline-directed medical therapy, or secondary cardiomyopathy (tachycardia mediated, thyroid mediated, etc.) in which the underlying cause is potentially treatable.”	IIb	C
“WCDs may be appropriate as bridging therapy in situation associated with increased risk of death in which ICDs have been shown to reduce SCD but not overall survival such as within 40 D of MI.”	IIb	C
“WCDs should not be used when nonarrhythmic risk is expected to significantly exceed arrhythmic risk, particularly in patients who are not expected to survive >6 mo.”	III	C

AHA: American Heart Association; COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; SCD: sudden cardiac death; WCD: wearable cardioverter defibrillator.

The AHA, ACC and HRS do not have specific recommendations for home use of AEDs, but state the following:

“External defibrillation can save lives when used within minutes of the onset of VF. The AED is an efficient method of delivering defibrillation to persons experiencing out-of- hospital cardiac arrest….”

American Heart Association

In 2020, the AHA published guidelines regarding cardiopulmonary resuscitation and emergency cardiovascular care for pediatrics.  There is no specific recommendation for AEDs, but they do state the following:

“However, in the out-of-hospital setting, a single rescuer who does not have access to a cell phone should begin CPR (compressions-airway-breathing) for infants and children before calling for help because respiratory arrest is the most common cause of cardiac arrest and help may not be nearby. In the event of sudden witnessed collapse, rescuers should use an available automatic external defibrillator (AED), because early defibrillation can be lifesaving.”

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

AICD, Wearable Cardioverter Defibrillator, Wearable Vest, LifeCor WCD System, LifeVest, Wearable Cardiac Defibrillator

APPROVED BY GOVERNING BODIES:

The U.S. Food and Drug Administration (FDA) approved the Lifecor WCD® 2000 system via premarket application approval in December 2001 for “adult patients who are at risk for cardiac arrest and are either not candidates for or refuse an implantable defibrillator.” The vest was renamed and is now called the LifeVest.

In 2015, FDA approved the LifeVest “for certain children who are at risk for sudden cardiac arrest, but are not candidates for an implantable defibrillator due to certain medical conditions or lack of parental consent.”

In 2021, the FDA approved the ASSURE® WCD for adult patients at risk for SCA who are not candidates for (or refuse) an ICD.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan.  

CURRENT CODING:

CPT Codes:

93292	Interrogation device evaluation (in person) with physician analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system
93745	Initial set-up and programming by a physician or other qualified   health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events

 

HCPC Codes:

E0617	External defibrillator with integrated electrocardiogram analysis
K0606	Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0607	Replacement battery for automated external defibrillator, garment type only, each
K0608	Replacement garment for use with automated external defibrillator, each
K0609	Replacement electrodes for use with automated external defibrillator, garment type only, each

REFERENCES:

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POLICY HISTORY:

Medical Policy Panel, January 2014

Medical Policy Group, July 2014 (4): Portions of the original policy 168 “Cardioverter Defibrillators: Implantable, Wearable, or External” were removed and placed on this policy (557) pertaining to the wearable and external defibrillators. No changes were made to the policy at this time.  Key Points and References were updated.

Medical Review Committee, August 2014

Available for comment August 20 through October 3, 2014

Medical Policy Panel, January 2015

Medical Policy Group, January 2015 (4): Updates to Key Points and References.  Policy statement rearranged to be more easily read.  Policy statement intent unchanged.

Medical Policy Panel, May 2016

Medical Policy Group, June 2016 (4): Updates to Description, Key Points, Approved Governing Bodies, and References. Added policy statements to include investigational conditions for clarification.  Policy intent unchanged.

Medical Policy Panel, May 2017

Medical Policy Group, June 2017 (4): Updates to Key Points and References.  No change to policy statements.

Medical Policy Panel, May 2018

Medical Policy Group, June 2018 (4): Updates to Description, Key Points, and References.  No change to policy statement.

Medical Policy Group, October 2018 (4): Clarification made to policy statement.  No change in intent of statements.

Medical Policy Group, February 2019 (4): Updates to Policy statement regarding nonischemic dilated cardiomyopathy.  Effective 3/1/19, newly diagnosed dilated cardiomyopathy is medically necessary for WCD.

Medical Policy Administrative Committee: March 2019

Available for comments: February 25, 2019 – April 11, 2019.

Medical Policy Panel, May 2019

Medical Policy Group, May 2019 (4): Updates to Description, Key Points, and References. No change to policy statements.

Medical Policy Panel, May 2020

Medical Policy Group, June 2020 (4): Updates to Description and Key Points.  No change to policy statements.

Medical Policy Group, September 2020 (4): Clarified investigational statement regarding WCDs. Intent unchanged. Added “in the absence of eligible criteria as mentioned above”.

Medical Policy Panel, May 2021

Medical Policy Group, June 2021 (4): Updates to Key Points and References.  Policy statement updated to remove “not medically necessary,” no change to policy intent.  The following references were removed: Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias; AVID Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias.

Medical Policy Panel, May 2022

Medical Policy Group, May 2022 (4): Updates to Policy statements, Key Points, Approved by Governing Bodies, and References.  Policy statements updated to reflect coverage for awaiting ICD placement following a CABG or PCI with angioplasty and/or stenting within the past 3 months (with or without MI) if all other criteria is met. Removed policy statements Effective for dates of service prior to March 1, 2019.

Medical Policy Administration Committee: May 2022

Available for Comment: June 1, 2022 – July 16, 2022

Medical Policy Panel, May 2023

Medical Policy Group, June 2023 (4): Updates to Key Points, Approved by Governing Bodies, Benefit Application, and References. No change to policy statements.

Medical Policy Group, December 2023 (4):  Updates to Policy section, Description, Key Points, and References.  Added coverage criteria for AED use in certain children ages 1-8. 

Medical Policy Administration Committee: January 2024

Available for comment January 1, 2024 - February 15, 2024

Medical Policy Panel, May 2024

Medical Policy Group, May 2024 (4): Updates to Key Points and References.  No change to policy statements.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

 

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

 

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.