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Indications

(1) Does the request meet this criterion: Primary prevention — high SCD risk without occurrence of a life-threatening VT or VF and ≥ 1 (a–i): a. Ischemic cardiomyopathy with NYHA functional Class I symptoms and both: i. History of myocardial infarction (MI) ≥ 40 days prior to ICD treatment? 
(2) Does the request meet this criterion: QTc greater than 500 msec? 
(3) Does the request meet this criterion: LQT2 or LQT3? 
(4) Does the request meet this criterion: Family history of sudden death g. Brugada syndrome (BrS) and ≥ 1: i. Prior cardiac arrest ii. Spontaneous sustained VT with/without syncope iii. Spontaneous diagnostic type 1 ECG with positive history of syncope, seizure or nocturnal agonal respiration after noncardiac causes have been ruled out? 
(5) Does the request meet this criterion: Secondary prevention — Member has experienced occurrence of life-threatening clinical event associated with ventricular arrhythmic events (e.g., sustained VT) when reversible causes (e.g., acute ischemia, drug toxicity, electrolyte abnormalities, etc.) have been excluded? 

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Implantable Cardioverter Defibrillators
Proprietary information of EmblemHealth. © 2026 EmblemHealth & Affiliates POLICY NUMBER LAST REVIEW MG.MM.SU.60aC5 May 8, 2026

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Definitions Transvenous implantable cardiac defibrillator (ICD)
(Aka thoracotomy systems) Device designed to monitor heart rate, recognize ventricular fibrillation (VF) or ventricular tachycardia (VT) and deliver electrical shock to terminate these arrhythmias in order to reduce the risk of sudden cardiac death (SCD). The reasons for device-implantation are twofold:

  1. Primary prevention — those patients at high risk for SCD who have not experienced life- threatening VTs or VF
  2. Secondary prevention — those patients who have experienced a potentially life- threatening episode of VT (i.e., near SCD) The standard ICD involves placement of a generator in the subcutaneous tissue of the chest wall. Transvenous leads are attached to the generator and threaded intravenously into the endocardium. The leads sense and transmit information on cardiac rhythm to the generator which analyzes the rhythm information and produces an electrical shock when a malignant arrhythmia is recognized. Subcutaneous implantable cardiac defibrillator (S-ICD) A defibrillator device that is implanted is implanted under the skin on the side of the chest below the arm pit. The pulse generator is connected to the electrode which is implanted under the skin from the device pocket along the rib margin to the breastbone with the use of the insertion tool. The electrodes sense the cardiac rhythm and deliver countershocks through the subcutaneous

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Page 2 of 15 (Aka nonthoracotomy systems) tissue of the chest wall.
The S-ICD does not require a thoracotomy and does not employ transvenous leads. The goal of this device is to reduce lead-related complications. Related Medical Guidelines Automatic External Defibrillators Cardiac Resynchronization Therapy (Biventricular Pacing) — MCG #ACG: A-0167 (AC) Indications for Coverage Implantable cardiac defibrillation therapy using an FDA-approved ICD (thoracotomy system) or S-ICD (non- thoracotomy system) is considered medically necessary when the following criteria (I–III) are met: I. Transvenous ICD — adults Considered medically necessary when member is not a candidate for cardiac revascularization (i.e., coronary artery bypass graft [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) is not clinically appropriate and one of the following criteria (1 or 2) is met:

  1. Primary prevention — high SCD risk without occurrence of a life-threatening VT or VF and ≥ 1 (a–i):
    a. Ischemic cardiomyopathy with NYHA functional Class I symptoms and both:
    i. History of myocardial infarction (MI) ≥ 40 days prior to ICD treatment
    ii. LVEF ≤ 30%
    b. Ischemic cardiomyopathy with NYHA functional Class II or Class III symptoms and both:
    i. History of MI ≥ 40 days prior to ICD treatment
    ii. LVEF ≤ 35%
    c. Nonischemic dilated cardiomyopathy and all:
    i. LVEF ≤ 35%
    ii. Reversible causes excluded
    iii. Refractory to optimal medical therapy (defined as 3 months of maximally titrated doses, as tolerated, of an ACE inhibitor, beta-blocker and diuretic) d. Hypertrophic cardiomyopathy (HCM) with ≥ 1 of the following major SCD risk factors:
    i. History of premature HCM-related sudden death in ≥ 1 first degree relative at < 50 years of age
    ii. LVH ≥ 30 mm iii. Documented VT with heart rates ≥ 120 beats per minute on 24-hour Holter monitor

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Page 3 of 15 iv. Left ventricular wall thickness ≥ 3cm v. Hypotensive response to exercise treadmill testing (ETT) vi. Prior unexplained syncope that is inconsistent with neurocardiogenic origin
e. Documented LMNA gene mutations (lamin A/C deficiency) with either:
i. Cardiomyopathy ii. Symptomatic cardiac arrhythmias
f. Long QT syndrome (LQTS) and any:
i. Prior cardiac arrest
ii. Syncope and/or VT while on beta blocker pharmacotherapy
iii. Asymptomatic with ≥1 of the following risk factors for SCD:

  • QTc greater than 500 msec
  • LQT2 or LQT3
  • Family history of sudden death g. Brugada syndrome (BrS) and ≥ 1:
    i. Prior cardiac arrest ii. Spontaneous sustained VT with/without syncope iii. Spontaneous diagnostic type 1 ECG with positive history of syncope, seizure or nocturnal agonal respiration after noncardiac causes have been ruled out iv. Development of VF during programmed electrical stimulation
    h. Catecholaminergic polymorphic ventricular tachycardia (CPVT) and ≥ 1:
    i. Prior cardiac arrest
    ii. Recurrent syncope
    iii. Polymorphic/bidirectional VT unresponsive to medical management or left cardiac sympathetic denervation
    i. Cardiac sarcoidosis, giant cell myocarditis or Chagas disease (regardless of LV ejection fraction)
    j. LV non-compaction cardiomyopathy with either of the following: i. Positive family SCD history
    ii. Impaired LVEF of < 50 % k. Arrhythmogenic right ventricular dysplasia (ARVD)
    1. Secondary prevention — Member has experienced occurrence of life-threatening clinical event associated with ventricular arrhythmic events (e.g., sustained VT) when reversible causes (e.g., acute ischemia, drug toxicity, electrolyte abnormalities, etc.) have been excluded

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Page 4 of 15 II. Transvenous ICD — pediatrics Considered medically necessary when ≥ 1 of the following criteria (1–9) are met:

  1. Prior cardiac arrest after reversible causes excluded
  2. Symptomatic sustained VT in association with congenital heart disease in members who have undergone hemodynamic and electrophysiologic evaluation
  3. Congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias
  4. Hypertrophic cardiomyopathy (HCM) with ≥ 1 of the following SCD risk factors:
    a. History of premature HCM-related sudden death in ≥ 1 first-degree relative at < 50 years of age b. Massive left ventricular hypertrophy
    c. Prior unexplained syncope that is inconsistent with neurocardiogenic origin
  5. Documented LMNA gene mutations (lamin A/C deficiency) with ≥ 1:
    a. Cardiomyopathy b. Symptomatic cardiac arrhythmias
  6. Long QT syndrome (LQTS) and > 1:
    a. Prior cardiac arrest b. Recurrent syncopal events while on beta blocker pharmacotherapy
  7. Brugada syndrome (BrS) and ≥ 1:
    a. Prior cardiac arrest b. Documented spontaneous sustained ventricular tachycardia (VT) with/without syncope
    c. Spontaneous diagnostic type 1 ECG with a history of syncope, seizure or nocturnal agonal respiration after noncardiac causes have been excluded
    d. Development of VF during programmed electrical stimulation
  8. Catecholaminergic polymorphic ventricular tachycardia (CPVT) and ≥ 1:
    a. Prior cardiac arrest b. Recurrent syncope c. Polymorphic/bidirectional VT unresponsive to medical management or left cardiac sympathetic denervation
    III. S-ICD — adults or pediatrics Considered medically necessary for members who meet the transvenous ICD clinical criteria above and who do not have symptomatic bradycardia, incessant VT (or spontaneous frequently recurring VT) that is reliably terminated with anti-tachycardia pacing or who have previous endocarditis or infection associated with conventional ICDs.

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Page 5 of 15

Note: EmblemHealth considers the use of an FDA-approved implantable cardioverter defibrillator (ICD) device, combined with cardiac resynchronization therapy (i.e., CRT/ICD), to be medically necessary when Resynchronization (Biventricular Pacing) criteria are met (MCG #ACG: A-0167 (AC).

Limitations/Exclusions The use of either a subcutaneous or transvenous ICD is considered investigational and not medically necessary for clinical conditions other than those listed above, as well as when the specific criteria are not met.
Implantable cardioverter defibrillators with a built -in ST-segment monitoring feature (aka ICD -based ischemia monitors) are not considered medically necessary for any indication (in adults or children) due to insufficient evidence of therapeutic value.
Cardioverter-defibrillators are not considered medically necessary when other disease processes are present that clearly and severely limit estimated life expectancy to less than one 1 year. EmblemHealth will cover surveillance of ICDs as a face-to-face or remote service to monitor behavior of the device, to investigate symptoms such as post-event shock, and syncope, ICD malfunction or device failure. Surveillance of ICDs is also indicated to program device evaluation and adjustment and for patients prior to surgery or other procedures to modify or disable the device during the procedure. Remote interrogation is a single 90-day service, while in-person interrogation can be reported for each day it is performed. The replacement of an ICD pulse generator/leads is considered medically necessary when:

  1. Equipment is damaged or malfunctioning
  2. Manufacturer product labeling details medically necessary replacement scenario(s)
  3. Change in member's medical condition
    Procedure Codes
    0571T Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed 0572T Insertion of substernal implantable defibrillator electrode 0573T Removal of substernal implantable defibrillator electrode 0574T Repositioning of previously implanted substernal implantable defibrillator-pacing electrode 0575T Programming device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional 0576T Interrogation device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter 0577T Electrophysiologic evaluation of implantable cardioverter-defibrillator system with substernal electrode (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and

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Page 6 of 15 programming or reprogramming of sensing or therapeutic parameters) 0578T Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional 0579T Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results 0580T Removal of substernal implantable defibrillator pulse generator only 0614T Removal and replacement of substernal implantable defibrillator pulse generator 0650T Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professional
33202 Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) 33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) 33215 Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode 33216 Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator 33217 Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator 33218 Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator 33220 Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator 33223 Relocation of skin pocket for implantable defibrillator 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure) 33226 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) 33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads 33231 Insertion of implantable defibrillator pulse generator only; with existing multiple leads 33240 Insertion of implantable defibrillator pulse generator only; with existing single lead 33241 Removal of implantable defibrillator pulse generator only 33243 Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy 33244 Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction 33249 Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber 33262 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system 33263 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator;

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Page 7 of 15 dual lead system 33264 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system 33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed 33271 Insertion of subcutaneous implantable defibrillator electrode 33272 Removal of subcutaneous implantable defibrillator electrode 33273 Repositioning of previously implanted subcutaneous implantable defibrillator electrode 93260 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system 93261 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system 93282 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead transvenous implantable defibrillator system 93283 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead transvenous implantable defibrillator system 93284 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; multiple lead transvenous implantable defibrillator system 93287 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system 93289 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements 93295 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional 93296 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results 93644 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) G0448 Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing

ICD-10 Diagnoses

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Page 8 of 15 B57.0 Acute Chagas' disease with heart involvement
B57.2 Chagas' disease (chronic) with heart involvement
D86.85 Sarcoid myocarditis
I01.1 Acute rheumatic endocarditis
I01.2 Acute rheumatic myocarditis
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction I21.9 Acute myocardial infarction
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I24.9 Acute ischemic heart disease, unspecified I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I25.112 Atherosclerotic heart disease of native coronary artery with refractory angina pectoris (eff. 10/1/2022) I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris I25.2 Old myocardial infarction I25.5 Ischemic cardiomyopathy I25.6 Silent myocardial ischemia I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris

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Page 9 of 15 I25.82 Chronic total occlusion of coronary artery I25.83 Coronary atherosclerosis due to lipid rich plaque I25.84 Coronary atherosclerosis due to calcified coronary lesion I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
I33.0 Acute and subacute infective endocarditis I33.9 Acute and subacute endocarditis, unspecified
I38 Endocarditis, valve unspecified
I40.1 Isolated myocarditis
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.2 Other hypertrophic cardiomyopathy
I42.3 Endomyocardial (eosinophilic) disease I42.4 Endocardial fibroelastosis
I42.5 Other restrictive cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
I43 Cardiomyopathy in diseases classified elsewhere
I45.81 Long QT syndrome
I45.89 Other specified conduction disorders
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified
I47.1 Supraventricular tachycardia I47.20 Ventricular tachycardia, unspecified (eff. 10/1/2022) I47.21 Torsades de pointes (eff. 10/1/2022) I47.29 Other ventricular tachycardia (eff. 10/1/2022) I47.9 Paroxysmal tachycardia, unspecified I49.01 Ventricular fibrillation
I49.02 Junctional premature depolarization
I49.3 Ventricular premature depolarization I49.8 Other specified cardiac arrhythmias
I49.9 Cardiac arrhythmia, unspecified
I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure

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Page 10 of 15 I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.84 End stage heart failure I50.9 Heart failure, unspecified
Q24.8 Other specified congenital malformations of heart
Q24.9 Congenital malformation of heart, unspecified
R55 Syncope and collapse
T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter
T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter
T82.110S Breakdown (mechanical) of cardiac electrode, sequela
T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
T82.111D Breakdown (mechanical) of cardiac pulse generator (battery), subsequent encounter
T82.111S Breakdown (mechanical) of cardiac pulse generator (battery), sequela
T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter
T82.118D Breakdown (mechanical) of other cardiac electronic device, subsequent encounter
T82.118S Breakdown (mechanical) of other cardiac electronic device, sequela
T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter
T82.119D Breakdown (mechanical) of unspecified cardiac electronic device, subsequent encounter
T82.119S Breakdown (mechanical) of unspecified cardiac electronic device, sequela
T82.120A Displacement of cardiac electrode, initial encounter
T82.120D Displacement of cardiac electrode, subsequent encounter
T82.120S Displacement of cardiac electrode, sequela
T82.121A Displacement of cardiac pulse generator (battery), initial encounter
T82.121D Displacement of cardiac pulse generator (battery), subsequent encounter
T82.121S Displacement of cardiac pulse generator (battery), sequela
T82.128A Displacement of other cardiac electronic device, initial encounter
T82.128D Displacement of other cardiac electronic device, subsequent encounter
T82.128S Displacement of other cardiac electronic device, sequela
T82.129A Displacement of unspecified cardiac electronic device, initial encounter
T82.129D Displacement of unspecified cardiac electronic device, subsequent encounter
T82.129S Displacement of unspecified cardiac electronic device, sequela
T82.190A Other mechanical complication of cardiac electrode, initial encounter
T82.190D Other mechanical complication of cardiac electrode, subsequent encounter
T82.190S Other mechanical complication of cardiac electrode, sequela
T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter
T82.191D Other mechanical complication of cardiac pulse generator (battery), subsequent encounter
T82.191S Other mechanical complication of cardiac pulse generator (battery), sequela

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Page 11 of 15 T82.198A Other mechanical complication of other cardiac electronic device, initial encounter
T82.198D Other mechanical complication of other cardiac electronic device, subsequent encounter
T82.198S Other mechanical complication of other cardiac electronic device, sequela
T82.199A Other mechanical complication of unspecified cardiac device, initial encounter
T82.199D Other mechanical complication of unspecified cardiac device, subsequent encounter
T82.199S Other mechanical complication of unspecified cardiac device, sequela
T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter
T82.6XXD Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter
T82.6XXS Infection and inflammatory reaction due to cardiac valve prosthesis, sequela
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.7XXD Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter
T82.7XXS Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela
Z00.6 Encounter for examination for normal comparison and control in clinical research program Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
Z76.82 Awaiting organ transplant status Z86.74 Personal history of sudden cardiac arrest References

  1. Greene HL. The implantable cardioverter-defibrillator. Clin Cardiol. 2000;23(5):315-326.
  2. Stanton MS, Bell GK. Economic outcomes of implantable cardioverter-defibrillators. Circulation. 2000;101(9):1067-1074.
  3. Eckardt L, Haverkamp W, Johna R, et al. Arrhythmias in heart failure: Current concepts of mechanisms and therapy. J Cardiovasc Electrophysiol. 2000;11(1):106-117.
  4. Bocka J. Automatic external defibrillation. eMedicine J. 2001;2(3), updated November 2018. http://www.emedicine.com/emerg/topic698.htm. Accessed May 12, 2026.
  5. Marenco JP, Wang PJ, Link MS, et al. Improving survival from sudden cardiac arrest: The role of the automated external defibrillator. JAMA. 2001;285(9):1193-1200.
  6. McDaniel CM, Berry VA, Haines DE, et al. Automatic external defibrillation of patients after myocardial infarction by family members: Practical aspects and psychological impact of training. Pacing Clin Electrophysiol. 1988;11(11 Pt 2):2029-2034.
  7. Cannom DS. Implantable cardioverter defibrillator trials: What's new? Curr Opin Cardiol. 2002;17(1):29-35.
  8. Schlapfer J, Rapp F, Kappenberger L, et al. Electrophysiologically guided amiodarone therapy versus the implantable cardioverter-defibrillator for sustained ventricular tachyarrhythmias after myocardial infarction: Results of long-term follow-up. J Am Coll Cardiol. 2002;39(11):1813-1819.
  9. Coats AJ. MADIT II, the Multi-center Autonomic Defibrillator Implantation Trial II stopped early for mortality reduction, has ICD therapy earned its evidence-based credentials? Int J Cardiol. 2002;82(1):1-5.
  10. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877-883.
  11. Swygman C, Wang PJ, Link MS, et al. Advances in implantable cardioverter defibrillators. Curr Opin Cardiol. 2002;17(1):24-28.

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  1. BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). Use of implantable cardioverter-defibrillators for prevention of sudden death in patients at high risk for ventricular arrhythmia. TEC Assessment Program. Chicago, IL: BCBSA; August 2002;17(10). Available at: http://www.bcbs.com/tec/vol17/17_10.html. Accessed February 21, 2005.
  2. Boehmer JP. Device therapy for heart failure. Am J Cardiol. 2003;91(6A):53D-59D.
  3. Gillis AM, Philippon F, Cassidy MR, et al. Guidelines for implantable cardioverter defibrillator follow-up in Canada: A consensus statement of the Canadian Working Group on Cardiac Pacing. Can J Cardiol. 2003;19(1):21-37.
  4. Ezekowitz JA, Armstrong PW, McAlister FA. Implantable cardioverter defibrillators in primary and secondary prevention: A systematic review of randomized, controlled trials. Ann Intern Med. 2003;138(6):445-452.
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  6. Center for Medicare and Medicaid Services (CMS). Implantable Automatic Defibrillators. National Coverage Determination v5
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  1. Exner DV. Implantable cardioverter defibrillator therapy for patients with less severe left ventricular dysfunction. Curr Opin Cardiol. 2009;24(1):61-67.
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  1. Epstein AE, Abraham WT, Bianco NR, et al. Wearable cardioverter-defibrillator use in patients perceived to be at high risk early post-myocardial infarction. J Am Coll Cardiol. 2013;62(21):2000-2007.
  2. Zei PC. Is the wearable cardioverter-defibrillator the answer for early post-myocardial infarction patients at risk for sudden death?: Mind the gap. J Am Coll Cardiol. 2013;62(21):2008-2009.
  3. Adler A, Halkin A, Viskin S. Wearable cardioverter-defibrillators. Circulation. 2013;127(7):854-860.
  4. Lambiase PD, Barr C, Theuns DAMJ, et al; on behalf of the EFFORTLESS Investigators. Worldwide experience with a totally subcutaneous implantable defibrillator: Early results from the EFFORTLESS S-ICD Registry. Eur Heart J. 2014;35(25):1657-1665.
  5. Gula LJ, Massel D, Krahn AD, et al. Is defibrillation testing still necessary? A decision analysis and Markov model. J Cardiovasc Electrophysiol. 2008;19(4):400-405.
  6. Bianchi S, Ricci RP, Biscione F, et al. Primary prevention implantation of cardioverter defibrillator without defibrillation threshold testing: 2-year follow-up. Pacing Clin Electrophysiol. 2009;32(5):573-578.
  7. Stefano B, Pietro RR, Maurizio G, et al. Defibrillation testing during implantable cardioverter-defibrillator implantation in Italian current practice: The Assessment of Long-term Induction clinical ValuE (ALIVE) project. Am Heart J. 2011;162(2):390-397.
  8. Russo AM, Chung MK. Is defibrillation testing necessary? Cardiol Clin. 2014;32(2):211-224.
  9. Healey JS, Hohnloser SH, Glikson M, et al; Shockless IMPLant Evaluation [SIMPLE] investigators. Cardioverter defibrillator implantation without induction of ventricular fibrillation: A single-blind, non-inferiority, randomised controlled trial (SIMPLE). Lancet. 2015;385(9970):785-791.
  10. Weinstock J, Selan J, Majithia A. Subcutaneous implantable cardioverter defibrillators. UpToDate Inc., Waltham, MA. Last reviewed April 2015.
  11. National Government Services. Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based. January 1, 2019. https://www.cms.gov/medicare-coverage- database/view/article.aspx?articleid=53018&ver=13&Date=&DocID=A53018&bc=hAAAABAAAAAA&=. Accessed May 12, 2026.
  12. NIH ClinicalTrials.gov. Extravascular ICD Pivotal Study (EV ICD). https://clinicaltrials.gov/ct2/show/NCT04060680?term=EV+ICD&draw=2&rank=1. Accessed May 12, 2026.
  13. Specialty matched clinical peer review. Revision History Company(ies) DATE REVISION EmblemHealth Jan. 23, 2026 Added coverage of the Aurora™ EV-ICD system (CPT: 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T and 0614T) EmblemHealth May 9, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Jul. 24, 2020 Added that substernal leads are investigational EmblemHealth ConnectiCare Jul. 8, 2020 Added arrhythmogenic right ventricular dysplasia (ARVD) to adult transvenous ICD section
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