External Defibrillators
Revised: 01-31-2012
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Overview
Eligible Providers
Eligible Recipients
Covered Services
Authorization
Billing
Overview
Automated External Defibrillators (AED) are used to administer an electric shock to the heart to stop ventricular fibrillation.
Eligible Providers
The following providers may provide external defibrillators:
 Medical suppliers
 Pharmacies
 Home health agencies
 Hospitals
 Indian Health Services
 Federally Qualified Health Center
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist
recipients for whom MHCP is not the primary payer.
MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.
Eligible Recipients
External Defibrillators are covered for all eligible MHCP recipients who meet medical necessity criteria.
Covered Services
Codes:
E0617: External defibrillator with integrated electrocardiogram analysis
K0606: Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0607-K0609: replacement accessories for garment-type defibrillator.
Automated non-wearable
Criteria
Rental for up to 13 months only and rental includes all necessary supplies. After 13 months rental, the AED belongs to the
recipient, and supplies may be purchased without authorization using A9999. Authorization requests must include expected
duration of need.
 A non-wearable AED will be approved for a recipient if they have one of the following conditions with implantation of a
defibrillator currently contraindicated:
 A documented episode of cardiac arrest due to ventricular fibrillation, not due to a transient or reversible cause
 A sustained ventricular tachyarrhythmia, lasting 30 seconds or longer, either spontaneous or induced during an
electrophysiologic (EP) study, not associated with acute myocardial infarction and not due to a transient or reversible cause
 Familial or inherited conditions with a high risk of life threatening ventricular tachyarrhythmia such as long QT syndrome or
hypertrophic cardiomyopathy
 Coronary artery disease with a prior documented myocardial infarction (more than 4 weeks prior to the external defibrillator
prescription) with a measured left ventricular ejection fraction less than or equal to 0.35 and inducible, sustained ventricular
tachycardia or ventricular fibrillation during an EP study (tested at least 4 weeks after the most recent myocardial infarction)
 Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 0.30. Recipients
must not have:
 Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
 Had a coronary artery bypass graft or percutaneous transluminal coronary angioplasty within the past 3 months
 Had an enzyme-positive MI within the past month
 Clinical symptoms or findings that would make them a candidate for coronary revascularization
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Recipients with ischemic dilated cardiomyopathy, documented prior myocardial infarction, New York Heart Association Class
II and III heart failure, and measured left ventricular ejection fraction ≤35%
Recipients with nonischemic dilated cardiomyopathy for greater than 3 months, New York Heart Association Class II and III
heart failure, and measured left ventricular ejection fraction ≤ 35%
Recipients who meet one or more of the previous criteria and have New York Heart Association Class IV heart failure
Recipient has a previously implanted defibrillator which now requires explanation and immediate replacement of the implanted
defibrillator is contraindicated
An AED will not be approved for recipients who:
 Currently have an implantable cardioverter- defibrillator (ICD)
 Lack a caregiver who is able to correctly use the AED, and is available to promptly use the AED 24 hours per day. If the
recipient does not have 24 hour awake caregivers, documentation must address how the recipient’s health will be assured
during sleep hours.
Wearable/Garment Type
Criteria
The device is rental for up to 13 months only, and rental includes all necessary supplies. After 13 months rental, the AED belongs
to the recipient, and supplies may be purchased without authorization. Authorization requests must include expected duration of
need.
An AED, wearable / garment type, will be approved for recipients over age 21 if they have one of the following conditions with
implantation of a defibrillator currently medically contraindicated or contraindicated due to a standard 40 or 90 day waiting period:
 A documented episode of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia.
These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) study, but may not be due to a
transient or reversible cause and may not occur during the first 48 hours of an acute myocardial infarction
 Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long QT syndrome or
hypertrophic cardiomyopathy
 Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less
than or equal to 0.35.
 Recipient has a previously implanted defibrillator which now requires explanation and immediate replacement of the implanted
defibrillator is contraindicated
An AED, garment type, will not be approved for recipients who:
 Currently have an implantable cardioverter- defibrillator (ICD)
 Have hearing, vision, or developmental problems that may prevent interpreting device messages
 Are on medication that may impair proper response to device alarms
 Are unable or unwilling to wear the device continuously, except when bathing
Authorization
Authorization is always required.
Submit authorization request and required documentation to the authorization medical review agent.
Submit chart documentation to support history, diagnosis, treatment plan, etc.
Billing
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Use MN–ITS 837P Professional. Refer to the MN–ITS User Guide for DME/Med Supply/Prosthetics/Orthotics for billing
instructions.
The HCPCS codes and modifiers on submitted claims must be identical to the approved authorization to prevent a denial.
If the recipient has Medicare, MHCP will pay the deductible / co-insurance on any units for which Medicare made payment.