Medicare Coverage for CRT-D
Last updated: September 2009
Cardiac resynchronization therapy defibrillator (CRT-D) is composed of two main functions: cardiac resynchronization therapy (CRT) and defibrillation (D). While a Medicare National Coverage Determination (NCD) for Implantable Cardioverter Defibrillators (ICDs) currently exists, there is no NCD for CRT. There is also no indication that Medicare is considering an NCD for CRT at this time.
As a result, the coverage criteria for CRT-D therapy must satisfy both:
• The NCD for ICDs1; and
• Local Coverage Determinations (LCDs) for CRT, if one exists.
Note: Currently only Idaho and North Carolina have LCDs for CRT (See Table 1 for LCD details). In the absence of an LCD for CRT, the criteria under the ICD NCD should be sufficient for coverage, provided the CRT functionality is deemed reasonable and medically necessary.
A patient must meet the medical necessity requirements for the above therapies to receive benefits under the Medicare program. Also note, Medicare does not preauthorize medical procedures.
Click here to view full document with Medicare local coverage decisions and
Private Payer Policies.
Private Payer Coverage for CRT-D
Coverage for CRT-D therapy will vary by non-Medicare private payer. As such, it is best to determine the coverage for each patient prior to rendering medical services. The most effective way to determine whether coverage for a non-Medicare patient is available for the hospital and physician costs is for the provider to research the patient’s coverage by contacting the payer regarding whether or not there is a coverage policy for CRT-D. Table 2 lists the coverage criteria for many of the top insurers in the United States for CRT-D therapy.
In many cases, providers may be required to submit a formal request for preauthorization of benefits prior to scheduling procedures. Preauthorization helps to clarify benefits and payment rates in advance, allowing both the provider and patient to make informed decisions about their care. The one exception to this general rule is Medicare. Medicare does not preauthorize medical procedures.
Click here to view full document with Medicare local coverage decisions and
Private Payer Policies.
- Centers for Medicare and Medicaid Services. National
Coverage Determination for Implantable Automatic Defibrillators (20.4). In:
Medicare Coverage Database. Effective January 27, 2005. Available at:
http://www.cms.hhs.gov/mcd/viewncd.asp. Accessed September 1, 2009.
Disclaimer:
Reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is presented for illustrative purposes only. This information does not constitute reimbursement or legal advice. Boston Scientific makes no representation or warranty regarding this information or its completeness, accuracy, timeliness, or applicability with a particular patient. Boston Scientific specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information in this document. Boston Scientific encourages providers to submit accurate and appropriate claims for services. Laws, regulations and payer policies concerning reimbursement are complex and change frequently. Providers are responsible for making appropriate decisions relating to coding and reimbursement submissions. Accordingly, Boston Scientific recommends that you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage and reimbursement matters. Information included herein is current as of September 1, 2009, but is subject to change without notice. This piece reflects payment estimates only and is not a guarantee of payment. Actual reimbursement may vary. All patient care decisions must be based on medical necessity and appropriately documented.
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