Download Implantable Cardioverter Defibrillator ICD Compliance

PLACE LABEL HERE
Implantable Cardioverter Defibrillator
(ICD) Compliance Checklist
Patient Name: __________________________
Type of Procedure:  Single Chamber ICD
Patient Date of Birth: _________________
 Dual Chamber ICD
 BiV ICD (CRT-D)
Please check one of the following and answer the appropriate questions:
Secondary Prevention: Please check one of the following indications and give the
appropriate answer.
 Cardiac Arrest (due to ventricular arrhythmias without reversible causes)
Date of Cardiac Arrest:
Exception:
Cardiac arrest associated with acute MI or reversible ischemia?
 Yes STOP
 No
*If available please provide documentation of event and documentation that MI has been ruled out
 Sustained VT > 30 seconds (without reversible causes) or hemodynamic instability
Spontaneous VT:
Induced by Electrophysiology Study (EP study
must be performed > 48 hours after acute MI
or revascularization)
Sustained VT associated with acute MI,
reversible ischemia, electrolyte or medication
imbalance, acidosis?
 Yes
 No
Date of VT:
 Yes
 No
Date of EP study:
 Yes STOP 
 No
 Familial or Inherited Condition with high risk of life-threatening VT (e.g. long QT, HCM,
Brugada, etc.)
Disorder:
Primary Prevention WITHOUT inducible sustained VT on EP study: Please complete the
“Exclusions” section, then check one of the following indications and answer the
appropriate questions.
EXCLUSION CRITERIA *
New York Heart Association (NYHC) classification IV**(See exception below)
Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm?
Had CABG or PCI within the past 90 days?
Had acute MI within the past 40 days?
Candidate for CABG or PCI?
Life Expectancy < 1 year due to non-cardiac conditions?
 Yes STOP
 Yes STOP
 Yes STOP
 Yes STOP
 Yes STOP
 Yes STOP
 No
 No
 No
 No
 No
 No
*All Exclusion Criteria must be checked “NO” in order to meet ICD compliance criteria
**Medicare does allow Class IV failure if the patient meets all applicable CRT criteria
*3-33676*
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FORM 3-33676 REV. 09/2016
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PLACE LABEL HERE
Implantable Cardioverter Defibrillator
(ICD) Compliance Checklist
 Coronary Artery Disease with Documented Prior MI and EF  35%
EF  35%?
 Yes
 No STOP
EF value:
Study type:
Has the patient had a prior MI?
 Yes
 No STOP
Date of MI:
Study Type:
Has the patient had EP study with
inducible, sustained VT or VF?
 Yes  No STOP
Study Date:
Study Date:
 Documented Prior MI with EF  30%
EF  30%?
 Yes
 No STOP
EF value:
Study type:
Has the patient had a prior MI?
 Yes
 No STOP
Date of MI:
Study Type:
Study Date:
 Ischemic Cardiomyopathy with EF  35%
EF <= 35%
 Yes
 No STOP
Date:
EF:
Has the patient had a MI?
NYHA Class  II or  III
 Yes
 No STOP
Date:
Study:
 Yes

 No STOP

 GDMT
 Yes
 No
Study:
Reason:
 Non-Ischemic Cardiomyopathy > 3 months with EF
 35%
EF <= 35%
 Yes
 No STOP
Date:
EF:
Non-Ischemic Cardiomyopathy
> 3 months?
NYHA Class  II or  III
 Yes
 No STOP
Date:
Study:
 Yes
 No STOP
 GDMT
 Yes
 No
Study:
Reason:
DUAL CHAMBER IMPLANTATION: If implanting a dual chamber device, must answer the
following additional questions.
Pacing Indication:
Condition for Which Pacing is
Indicated:
On GDMT for > 3 months?
FORM 3-33676 REV. 09/2016
 No STOP
 Yes
 Complete Heart Block  2nd Degree Heart Block  Chronic A-Fib
 Bradycardia HR <50
 Sick Sinus Syndrome
 Other: __________________________________
Date:
 Yes
 No STOP
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PLACE LABEL HERE
Implantable Cardioverter Defibrillator
(ICD) Compliance Checklist
CRT-D IMPLANTATION: If implanting a CRT-D device, must answer the following
additional questions. Manufacturer specific indications for implantation may also apply.
EF <= 35%
 Yes
 No STOP
Date:
QRS ≥ 120ms or LBBB pattern
with QRS ≥ 130ms
 Yes
 No STOP
QRS Duration ____________Date:______________
NYHA Class  II  III or  IV
Heart failure? (Check one) i.e.
absence of Class I heart failure
 Yes
 No STOP
Date:
On GDMT for > 3 months?
 Yes
 No STOP

EF:
Study :

If the above ICD compliance criteria are not met, the Medicare coverage/payment criteria will not
be met. Physician to provide/document justification or medical reason for implanting ICD:
____________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________
Attending Physician Name (Print): ____________________________
_______________
Date
__________ __________________________
Time
Attending Physician Signature
_______________
Date
__________ __________________________
Time
GMC Representative Signature
FORM 3-33676 REV. 09/2016
__________
PID #
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