Implantable Cardioverter Defibrillators (ICDs) — NCD 110 | CMS Coverage Update

CMS modified NCD 110 for implantable cardioverter defibrillators (ICDs), effective March 7, 2026. Here's what billing teams need to know.

The Centers for Medicare & Medicaid Services updated NCD 110, the National Coverage Determination governing Medicare coverage of ICDs under the Prosthetic Devices benefit category. This modification affects cardiology, electrophysiology, and cardiac surgery billing teams across the country. No specific CPT or HCPCS codes are listed in this version of the policy — but the medical necessity criteria are detailed and the documentation requirements are strict.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Implantable Cardioverter Defibrillators (ICDs)
Policy Code	NCD 110
Change Type	Modified
Effective Date	March 7, 2026
Impact Level	High
Specialties Affected	Cardiology, Electrophysiology, Cardiac Surgery, Cardiac Electrophysiology, Hospital Outpatient
Key Action	Audit your ICD implant documentation now — shared decision making records are required for primary prevention patients before the March 7, 2026 effective date applies to new claims

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CMS ICD Coverage Criteria and Medical Necessity Requirements 2026

The CMS ICD coverage policy under NCD 110 divides covered patients into four distinct groups. Each group has its own medical necessity criteria. Miss one element, and you're looking at a claim denial.

The coverage criteria effective for services on or after February 15, 2018 remain the foundation of NCD 110. The March 7, 2026 modification builds on this framework. Your billing team needs to understand every group before submitting claims.

Group 1: Secondary Prevention — Prior VT/VF History

CMS covers ICD implantation for patients with a personal history of sustained ventricular tachyarrhythmia (VT) or cardiac arrest due to ventricular fibrillation (VF). The patient must have documented either:

#	Covered Indication Copy
1	A sustained VT episode — spontaneous or induced by an electrophysiology (EP) study — not associated with an acute myocardial infarction (MI) and not due to a transient or reversible cause, or
2	Cardiac arrest due to VF, not due to a transient or reversible cause

This group is the clearest path to reimbursement. The documentation burden is relatively straightforward: you need the EP study or event record, and you need to rule out reversible causes. Get that in the chart before billing.

Group 2: Prior MI with LVEF ≤ 0.30

CMS covers ICD implantation for patients with a prior MI and a measured left ventricular ejection fraction (LVEF) at or below 0.30. Four disqualifying conditions apply — any one of them kills the coverage:

This is where claims get denied most often. A patient who had a stent placed eight weeks ago doesn't qualify yet. Your intake documentation needs to capture the exact dates of any prior procedures.

Shared decision making is required for Group 2 patients before initial ICD implantation. The encounter must occur between the patient and a physician (as defined in §1861(r)(1) of the Social Security Act) or a qualified non-physician practitioner — meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5). The shared decision making encounter must use an evidence-based decision tool on ICDs. It can happen at a separate visit, but it must happen before implantation.

Document the shared decision making encounter in the chart. If it's not there, prior authorization won't protect you — the claim will come back.

Group 3: Severe Ischemic Dilated Cardiomyopathy, No Prior VT/VF

CMS covers ICDs for patients with severe, ischemic, dilated cardiomyopathy who have no personal history of sustained VT or cardiac arrest due to VF, and who have NYHA Class II or III heart failure with LVEF ≤ 35%. The same three disqualifying conditions from Group 2 apply here:

#	Covered Indication Copy
1	CABG or PCI within the past three months
2	MI within the past 40 days
3	Candidacy for coronary revascularization

Shared decision making is required for Group 3 — same standards, same documentation requirements as Group 2.

Group 4: Severe Non-Ischemic Dilated Cardiomyopathy, No Prior VT/VF

Group 4 mirrors Group 3 but for non-ischemic dilated cardiomyopathy. CMS covers ICDs here when the patient has NYHA Class II or III heart failure, LVEF ≤ 35%, and has been on optimal medical therapy for at least three months. The same disqualifying conditions apply.

That three-month optimal medical therapy requirement is a common documentation gap. Your clinical team needs to record therapy start dates. Without them, you can't prove the patient qualifies — and the claim goes down.

Shared decision making is required for Group 4 as well. Same rules, same documentation standards.

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CMS ICD Exclusions and Non-Covered Indications

NCD 110 is specific about who doesn't qualify. These aren't gray areas — they're hard stops.

Patients with NYHA Class IV heart failure are excluded from Group 2 coverage. The policy draws a clear line: Class II and III are covered for primary prevention; Class IV is not.

Patients who recently had revascularization procedures — CABG or PCI within the past three months — are excluded across Groups 2, 3, and 4. The same 40-day exclusion applies after an acute MI. CMS wants the acute event to resolve before an ICD is implanted under primary prevention coverage.

Patients who are candidates for coronary revascularization are also excluded from Groups 2, 3, and 4. This one requires clinical judgment, and it needs to be documented explicitly. Your physician needs to state in the record that the patient is not a revascularization candidate. Leaving it implied won't hold up on audit.

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Coverage Indications at a Glance

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CMS ICD Billing Guidelines and Action Items 2026

The real risk with ICD billing under NCD 110 isn't understanding the coverage groups — it's documentation gaps on complex cases. Here's what to do before and after the March 7, 2026 effective date.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for ICDs Under NCD 110

The policy document for NCD 110 (version 110-v5) does not list specific CPT or HCPCS codes. This is consistent with how CMS structures some NCDs — the coverage determination sets the medical necessity criteria, and the applicable billing codes are addressed through related LCDs issued by Medicare Administrative Contractors or through the CMS Claims Processing Manual.

Your billing team should work directly with your MAC to confirm the current procedure codes for ICD implantation, generator replacements, and lead procedures. ICD implant billing typically involves HCPCS/CPT codes for device implantation and separately billable device charges — but verify the exact code set with your MAC, as regional billing guidelines vary.

For diagnosis coding, your ICD-10-CM codes need to reflect the specific indication: the underlying cardiomyopathy, prior MI, LVEF documentation, and NYHA class all need to map to the diagnosis codes on your claim. If your current charge capture doesn't capture NYHA class as a diagnosis modifier, that's a gap worth fixing before March 7, 2026.

If you need help identifying the applicable procedure codes for ICD billing under NCD 110, loop in your billing consultant or MAC representative. Don't guess — ICD implant codes carry high reimbursement values and attract scrutiny.

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