TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

External defibrillators are covered for all eligible Medical Assistance and MinnesotaCare members who meet medical necessity criteria.

Covered Services

Codes: E0617, K0606-K0609

Automated Nonwearable AED
Automated nonwearable AEDs may be rented only for up to 13 months and the rental includes all necessary supplies. The AED belongs to the member after 13 months rental and supplies may be purchased without authorization using A9999. Authorization requests must include expected duration of need.

A nonwearable AED (E0617) will be approved for a member 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 four weeks before the external defibrillator prescription) with a measured left ventricular ejection fraction less than or equal to 35 percent and inducible, sustained ventricular tachycardia or ventricular fibrillation during an EP study (tested at least four weeks after the most recent myocardial infarction)

Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 30 percent. Members 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 three months

· Had an enzyme-positive myocardial infarction within the past month

· Clinical symptoms or findings that would make them a candidate for coronary revascularization

· Members with ischemic dilated cardiomyopathy, documented before myocardial infarction, New York Heart Association Class II and III heart failure, and measured left ventricular ejection fraction less than or equal to 35 percent

· Members with nonischemic dilated cardiomyopathy for greater than three months, New York Heart Association Class II and III heart failure, and measured left ventricular ejection fraction less than or equal to 35 percent

· Members who meet one or more of the previous criteria and have New York Heart Association Class IV heart failure

· Member 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 the following indications:

· The member has an implantable cardioverter-defibrillator (ICD); and

· The member lacks a caregiver who is able to correctly use the AED and is not CPR certified; and

· The member lacks a caregiver who is available to promptly use the AED 24 hours per day. If the member does not have 24-hour awake caregivers, documentation must address how the member’s health will be assured during sleep hours, including alarms and monitoring devices for caregivers.

Wearable/Garment-Type AED
The device may be rented for only up to 13 months, and rental includes all necessary supplies. The AED belongs to the member after 13 months rental and supplies may be purchased without authorization. Authorization requests must include expected duration of need.

A garment-type AED (K0606) will be approved for members if they meet the following criteria:

· Member has a chest circumference of 26 inches (66 centimeters) or greater and a weight of 41.3 pounds (18.75 kilograms) or greater; and

· The implantation of a defibrillator is currently medically contraindicated or contraindicated due to a standard 40 or 90-day waiting period; and

· Member has one of the following documented medical conditions:

· A documented episode of ventricular fibrillation or a sustained, ventricular tachyarrhythmia lasting 30 seconds or longer. 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; or

· Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long QT syndrome or hypertrophic cardiomyopathy; or

· Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 35 percent; or

· Member has a previously implanted defibrillator which now requires explanation and immediate replacement of the implanted defibrillator is contraindicated

A garment-type AED will not be approved for the following indications:

· The member has an implantable cardioverter-defibrillator (ICD); and

· The member has hearing, vision, or developmental problems that may prevent interpreting device messages; and

· The member takes medication that may impair proper response to device alarms; and

· The member is unable or unwilling to wear the device continuously, except when bathing.

Replacement batteries (K0607), garments (K0608), and electrodes (K0609) for use with AEDs are covered for member-owned AEDs when the original item no longer functions. Document in the medical record that the original item is no longer functional.

Authorization

Authorization is always required. Submit authorization request and required documentation to the Medical Review Agent. Submit chart documentation to support history, diagnosis, treatment plan, or similar.

Billing

Use MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS User Guide for billing instructions.

· The HCPCS codes and modifiers on submitted claims must be identical to the approved authorization to prevent a denial.

· If the member has Medicare, MHCP will pay the deductible or co-insurance on any units for which Medicare made payment.

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