When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Brendorp B, Elming H, Jun L, et al. QTc interval as a guide to select those patients with congestive heart failure and reduced left ventricular systolic function who will benefit from antiarrhythmic treatment with dofetilide. Circulation. 2001; 103:1422-1427.
Dofetilide (Tikosyn®). American Hospital Formulary Service (AHFS). Drug Information 2019. [Lexi-comp Web site]. 02/22/2019. Available at: http://online.lexi.com/lco/action/home# [via subscription only]. Accessed September 06, 2019.
Dofetilide (Tikosyn®). Elsevier Gold's Standard Clinical Pharmacology Compendium. [ClinicalKey Web site]. 09/04/2019. Available at: https://www.clinicalkey.com/#!/content/drug_monograph/6-s2.0-705?scrollTo=%23References. [via subscription only]. Accessed September 06, 2019.
Dofetilide(Tikosyn®). Micromedex® 2.0 Healthcare Series. DrugDex®. Dofetilide. [Micromedex Web site]. 08/28/2019. Available at: http://www.micromedexsolutions.com/micromedex2/librarian/ [via subscription only]. Accessed September 06, 2019.
Kaber L. Dofetilide, a new class III antiarrhythmic drug reduces hospital admissions for congestive heart failure - Secondary endpoints of the DIAMOND-CHF study (abstract). J Am Coll Cardiol. 1998; 31(suppl 2A):31.
Kober L, Bloch Thomsen PE, Moller M, et al. Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial. Lancet. 2000; 356:2052-2058.
Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function. A Danish Investigations of Arrhythmia and Mortality ON Dofetilide (DIAMOND) substudy. Circulation. 2001; 104:292- 296.
Pfizer, Inc. Tikosyn® (dofetilide) FAQs. [Pfizer Web site]. New York, NY; 2019. Available at: https://www.pfizerpro.com/product/tikosyn/af/support/faqs. Accessed September 06, 2019.
Pfizer, Inc. Tikosyn® (dofetilide) [prescribing information]. New York, NY; Revised August 2019. Available at: http://labeling.pfizer.com/ShowLabeling.aspx?id=639. Accessed September 06, 2019.
Rousseau MF, Massart PE, Galanti L, et al. Contrasting effects of intravenous dofetilide and amiodarone on cardiac sympathetic drive in patients with congestive heart failure (abstract). J Am Coll Cardiol. 1998; 31(suppl 2A):32.
Torp-Pedersen C. Dofetilide: a new class III antiarrhythmic drug which is safe in patients with congestive heart failure (abstract). J Am Coll Cardiol. 1998; 31(suppl 2A):160.
US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs @ FDA. Drug details: dofetilide (Tikosyn®). [FDA Web site]. 08/08/2019. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm . Accessed September 06, 2019.
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I48.20 Chronic atrial fibrillation, unspecified
I48.3 Typical atrial flutter
I48.4 Atypical atrial flutter
NOT MEDICALLY NECESSARY
I48.0 Paroxysmal atrial fibrillation
The following ICD-10 CM codes have been termed from this policy:
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation