PLACE LABEL HERE

Implantable CardioverterDefibrillator

(ICD) Compliance Checklist

Patient Name: ______Patient Date of Birth: ______

Type of Procedure: Single Chamber ICD  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 VT30 seconds (without reversible causes)or hemodynamic instability
Spontaneous VT: /  Yes /  No / Date of VT:
Induced by Electrophysiology Study (EP study must be performed > 48 hours after acute MI or revascularization) /  Yes /  No / Date of EP study:
Sustained VT associated with acute MI, reversible ischemia, electrolyte or medication imbalance, acidosis? /  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) / Yes STOP / No
Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm? / Yes STOP / No
Had CABG or PCI within the past 90 days? / Yes STOP / No
Had acute MI within the past 40 days? / Yes STOP / No
Candidate for CABG or PCI? / Yes STOP / No
Life Expectancy < 1 year due to non-cardiac conditions? / Yes STOP / No

*All Exclusion Criteria must be checked “NO” inorder to meet ICD compliance criteria

**Medicare does allow Class IV failure if the patient meets all applicable CRT criteria

*3-33676*FORM 3-33676 REV. 09/2016 Page 1 of 3

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: / Study Date:
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:

Documented Prior MI with EF  30%

EF  30%? /  Yes /  No STOP / EF value: / Study type: / Study Date:
Has the patient had a prior MI? /  Yes /  No STOP / Date of MI: / Study Type:

Ischemic Cardiomyopathy with EF35%

EF <= 35% /  Yes /  No STOP / Date: / EF: / Study:
Has the patient had a MI? /  Yes /  No STOP / Date: / Study:
NYHA Class  II or  III /  Yes /  No STOP
 GDMT /  Yes /  No / Reason:

Non-Ischemic Cardiomyopathy3 months with EF35%

EF <= 35% /  Yes /  No STOP / Date: / EF: / Study:
Non-Ischemic Cardiomyopathy > 3 months? /  Yes /  No STOP / Date: / Study:
NYHA Class  II or  III /  Yes /  No STOP
 GDMT /  Yes /  No / Reason:

DUAL CHAMBER IMPLANTATION: If implanting a dual chamber device, must answer the following additional questions.

Pacing Indication: /  Yes /  No STOP
Condition for Which Pacing is Indicated: / Complete Heart Block  2nd Degree Heart Block Chronic A-Fib
Bradycardia HR <50 Sick Sinus Syndrome
Other:______
Date:
On GDMT for > 3 months? /  Yes /  No STOP

FORM 3-33676 REV. 09/2016 Page 1 of 3

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: / EF: / Study :
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
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): ______

______

DateTimeAttending Physician SignaturePID #

______

DateTimeGMC Representative Signature

FORM 3-33676 REV. 09/2016 Page 1 of 3