pacemaker for sick sinus syndrome

medicare

by Tracey_E - 2019-11-22 22:11:20

If Medicare doesn't cover it, supplemental insurance usually won't cover it either.  It doesn't have anything to do with the doctor or practice. Someone in the cardiologist's office should know a way around this. Surely it's not the first time it's come up. 

I agree with Tracey

by AgentX86 - 2019-11-23 00:28:07

Find an EP who will work with you.  Actually, I don't believe medicare has this restriction.  Sotalol slows the heart, so some with AF need a pacemaker to maintain heart rate when on sotalol.  In fact, my EP was talking about that exact scenareo with me before I really needed one.  I also have Afib (and flutter) with SSS (though have private insurance).  any insurance companies follow SS's guidance.

You may have a real problem

by donr - 2019-11-23 00:49:59

  THis is a messsy Medicare reimbursement issue.  Somewhere, something has gotten lost.  I rooted around in the Medicare manual on reimbursement - It says that Medicare will reimburse for PM's if the patient has non-reversible issues.  .  The key is the non-reversible.  If meds COMPLETELY take care of the problem, no payment.  Is your problem reversible or not?

I am NOT a professional coder - one who makes out bills for the provider.  That is extremely complex & even professional coders have trouble getting paid under some circumstances..  If your surgeon got denied, he/she will surrely chhallenge Medicare.  They want to get paid. The general rule is that if they do something on you & don't get reimbursed, you DO NOT HAVE to pay them.  I see that all the time on my Medicare EOB's.  There are more twists & turns in Medicare billing than in a bowl of spaghetti!  Ask their billing clerk what they are going to do.  They should tell you.

Don

Medicare Reimbursement for Pacemakers

by Marybird - 2019-11-23 20:07:09

Here's what I found when I was scratching all over the internet to find if there were current justifications for my getting a pacemaker for sick sinus syndrome that was aggrevated, if not outright caused by my taking a beta blocker to control  SVT: They were telling me I might well need a pacemaker and I was convinced Medicare would refuse to pay for it, and just tell me to stop taking the % $#@ metoprolol and that would solve all my problems! Fortunately, they didn't. 

The American College of Cardiology, American Heart Association, and Heart Rhythm Society have classified as a Class 1 ( benefits outweighing the risks, ie, necessary) indication, pacemaker implantation for documented symptomatic bradycardia (including frequent pauses) from required drug therapy for medical conditions ( for which there is no alternate therapy). This includes medication to control afib and other tachycardias. 

I think it was either in 2015 or 2017 that Medicare revised its guidelines for pacemaker implant reimbursement to include the above guidelines. They're lumped under "irreversible sinus node dysfunction" ***which is also a Class I indication. 

If a drug causing bradycardia can be discontinued, and substituted with another drug that doesn't cause bradycardia, or the condition can be corrected in some other manner, pacemaker implantation would likely not be reimbursed under these conditions. But for conditions such as afib, or other arrhythmias requiring treatment, options other than rate or rhythm controlling drugs aren't often an option, even ablation doesn't guarantee one will not need meds afterwords. So these conditions ( and I was informed my stubborn hypertension as well), fall under the category as those needing medication for which there are no alternatives.

In my case the EP initially switched the metoprolol associated with my bradycardia to diltiazem to determine if this would correct the bradycardia, and still control the SVT. He informed me that monitor results showed I had atrial tachycardia which wasn't always amenable to ablation, so controlling it with drugs and a pacemaker for the bradycardia would be a better option if the bradycardia continued with the diltiazem. It did, and I got the pacemaker, which was covered by Medicare with no problem. 

If someone has symptomatic bradycardia or significant sinus pauses ( ie, sick sinus syndrome) caused by any antiarrhythmia or rate control drug ( including Sotolol) they're taking for afib, it seems to me they'd be covered under Medicare's "irreversible sinus dysfunction" category as I was. Unless there's some indication that they think sotolol should be discontinued and another antiarrhythmia drug (s) should be substituted in the event it's causing that sinus node dysfunction, I can't see why they would exclude sotolol from the other "necessary drugs" and pay for the pacemaker. If that's the case there should be a footnote or note of explanation somewhere showing why sotolol is excluded from the other drugs.

***I saw this category on a Medicare questionnaire used to document a prospective pacemaker patient's indications for the pacemaker implant. I found it online, it lists all of the ACC, AHA and HRS conditions/ indications for pacemaker or ICD implants, and the form is filled out with the patient's demographic information and each condition/indication is answered with a yes or no. The condition "irreversible sinus node dysfunction" isn't too far down the list, and other than also filling out where indicated the patient's symptoms, that's sbout as far as you have to go before they say the pacer is indicated. There's a footnote for the "irreversible sinus node dysfunction" stating that bradycardia due to necessary medications to control conditions, for which there are no alternatives are included in this category.

Curious, in your shoes I'd discuss these guidelines with your cardiologist. Seems to me if he believes a pacemaker is indicated you'd fall under the "necessary medications" category and this should be covered by Medicare. He should be familiar with those guidelines and should be able to explain why sotolol isn't included with other drugs for these conditions ( if this is even the case.).

Good job, MArybird

by donr - 2019-11-24 00:30:34

You got more detail than I could find last night.  I did coding dor my PCP Daughter for a while, but never anything in the cardiology field.  All that made sense when compared to my experience w/ general medicine issues.

\Donr

Thanks, DONR

by Marybird - 2019-11-24 18:58:17

I guess I had quite a headstart looking up the issues of 1) indications for pacemakers, and 2) Medicare coverage for same. I'd never heard of or even considered bradycardia from needed medications as a reason for a pacemaker. I looked this up in January 2019 after my sister, who has afib and takes a low dose of diltiazem to control it got up one night, and collapsed with a HR of 38, was taken to the hospital where they spent a day trying to get the rate back up but it wouldn't go above 42, and they implanted a  pacemaker. They told her she had sick sinus syndrome, and while it might have been associated with the diltiazem she took, that was needed to control  her afib.

So I fell into that category later with metoprolol ( and diltiazem) being the associated drugs used to control my tachyarrythmia, and I didn't pass out ( came close a couple times), but mostly spent way too much of my time dragging myself around, begging off and postponing activities, pulling off the road when driving, etc. so I could rest/zone out waiting for my HR ( around 38-42) to go back up to functional levels. 

I have found nothing anywhere stating that Sotolol is excluded from the category of "necessary medications" associated with bradycardia as an indication for a pacemaker, and I don't believe sotolol is excluded. Looking back at this OP's other posts here, he/she also claimed that Medicare won't pay for pacemaker implantation for a  second degree heart block. Well, from further lookups I see it depends on the type of heart block ( Mobitz type 1 vs type 2,) causes of the heart block, location of the block, etc. So there's a lot of information there that the OP doesn't provide.

I don't know where the OP ( Curious D) is getting this information about Medicare coverage of pacemaker implantation, but it's very clear there is more to the story than he/she has posted here.

Here is a link from the CMS website showing a memo that lists the indications for pacemaker implantation. Medicare will cover the costs of pacemaker implantation, as well as subsequent care and monitoring, for these conditions. I see this memo is date 2013, I don't think there has been one that is more recent.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=267%20