405 IAC 5-28-4 - Single-chamber cardiac pacemaker implantation
Current through March 30, 2022
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
(a)
Reimbursement for single-chamber pacemaker implantation, in the absence of
special medical circumstances documented in the medical record that the
procedure is medically beneficial, is not available for the following:
(1) Syncope of undetermined cause.
(2) Sinus bradycardia without significant
symptoms.
(3) Sinoatrial block or
sinus arrest without significant symptoms.
(4) Prolonged PR intervals (slow ventricular
response) with atrial fibrillation without third degree atrial ventricular (AV)
block.
(5) Bradycardia during
sleep.
(6) Right bundle branch
block with left axis deviation and other forms of fascicular or bundle branch
blocks without significant signs or symptoms.
(7) Asymptomatic second degree AV block of
Mobitz Type I (Wenckebach).
(b) Reimbursement is available when the
medical record documents that the member has any of the following:
(1) Acquired complete (also referred to as
third degree) AV heart block.
(2)
Congenital complete heart block with severe bradycardia in relation to age or
significant physiological deficits or significant symptoms due to the
bradycardia.
(3) Second degree AV
heart block of Type II.
(4) Second
degree AV heart block of Type I.
(5) Sinus bradycardia associated with major
symptoms or substantial sinus bradycardia with heart rate less than fifty (50)
associated with dizziness or confusion. The correlation between symptoms and
bradycardia must be documented, or the symptoms must be clearly attributable to
the bradycardia rather than to some other cause.
(6) Sinus bradycardia of lesser severity
(heart rate fifty (50) to fifty-nine (59)) with dizziness or confusion. The
correlation between symptoms and bradycardia must be documented, or the
symptoms must be clearly attributable to the bradycardia rather than to some
other cause.
(7) Sinus bradycardia,
which is the consequence of long term necessary drug treatment for which there
is no acceptable alternative, when accompanied by significant symptoms. The
correlation between symptoms and bradycardia must be documented, or the
symptoms must be clearly attributable to the bradycardia rather than to some
other cause.
(8) Sinus node
dysfunction, with or without tachyarrhythmias or AV conduction block, when
accompanied by significant symptoms.
(9) Sinus node dysfunction, with or without
symptoms, when there are potentially life-threatening ventricular arrhythmias
or tachycardia secondary to the bradycardia.
(10) Bradycardia associated with
supraventricular tachycardia with high degree AV block, which is unresponsive
to appropriate pharmacological management and when the bradycardia is
associated with significant symptoms.
(11) Hypersensitive carotid sinus syndrome
with syncope due to bradycardia and unresponsive to prophylactic medical
measures.
(12) Bifascicular or
trifascicular block accompanied by syncope, which is attributed to transient
complete heart block after other plausible causes of syncope have been
reasonably excluded.
(13)
Prophylactic pacemaker use following recovery from acute myocardial infarction
during which there was temporary complete (third degree) or Mobitz Type II
second degree AV block in association with bundle branch block.
(14) Recurrent and refractory ventricular
tachycardia, overdrive pacing (pacing above the basal rate) to prevent
ventricular tachycardia.
(15)
Second degree AV heart block of Type I with the QRS complexes
prolonged.
Notes
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.