Inotropic Medicare Guidelines

Therapies:

  • Dobutamine
  • Dopamine
  • Milrinone


Qualifying Diagnoses:

  • American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Stage D Heart Failure (HF)
  • New York Heart Association (NYHA) Class IV HF


Provider notes must contain:

  • Qualifying diagnosis
  • GDMT prescribed, patient compliance, response, and unresolved HF symptoms
  • Reason for therapy (bridge or palliative treatment)
  • Following or consultative Cardiologist is a HF specialist
  • Documentation of HF symptoms before and during inpatient inotropic therapy, both subjective activity tolerance and objective findings


Documentation requirements with qualifying diagnosis:

  • Patient remains symptomatic despite optimal guideline directed medical therapy (GDMT)
    • Compliance with optimal medical therapy as defined by ACCF/AHA guideline–recommended therapies (primarily Class I recommendations). These include the use of diuretics, ACE (Apexus Certified Expert) inhibitors or ARB (Angiotensin Receptor Blocker) antagonists, beta-blockers, aldosterone antagonists, hydralazine & isosorbide dinitrate, and statins, as appropriate.
  • Prescribed at either:
    • As “Bridge” therapy for patients awaiting mechanical circulatory support (MCS)/cardiac transplantation
    • Palliative care for patients not eligible for either MCS/cardiac transplantation
  • Evaluation by a cardiologist with training in the management of advanced heart failure.
  • There has been a documented improvement of heart failure symptoms while on the inotropic drug during hospitalization.
  • Cardiologist evaluation every three months with documentation for the patient’s cardiac symptoms and the continuing response and need for therapy.
Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps LCD and PA (noridianmedicare.com). Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.

Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.

For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
  • The patient must be eligible for a defined Medicare benefit category.
  • Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
  • The case must meet all other applicable Medicare statutory and regulatory requirements.