HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-52-027
Topic:
External Counterpulsation
Section:
Diagnostic Medical
Effective Date:
October 1, 2023
Issued Date:
January 29, 2024
Last Revision Date:
December 2023
Annual Review:
December 2023
 
 

External counterpulsation (ECP), commonly referred to as enhanced external counterpulsation (EECP), is an outpatient non-invasive circulatory assist treatment for coronary artery disease refractory to medical and/or surgical therapy. A full course of therapy usually consists of up to 35 one (1) hour treatments, which may be offered once or twice daily, usually five (5) days per week.

Policy Position

ECP may be considered medically necessary using a United States Food and Drug Administration (U.S. FDA) approved device when BOTH of the following are met:

The individual has been diagnosed with disabling chronic stable angina (Class III or Class IV, Canadian Cardivascular Society Grading in Angina Pectoris Association); and

  • A cardiologist or cardiothoracic surgeon, documented that the individual  is not a candidate for surgical intervention, such as percutaneous coronary intervention (PCI) or cardiac bypass because:
    • Individual is inoperable, or at high risk of operative complications or post-operative failure; or
    • Individuals coronary anatomy is not readily amenable to such procedures; or
    • Individual has co-morbid states which create excessive risk; or
    • Individual is refractory to medical treatment.

ECP procedures not meeting the criteria as indicated in this policy are considered not medically necessary, including but not limited to the following conditions: 

  • Acute myocardial infarction; or
  • Cardiogenic shock; or
  • Erectile dysfunction; or
  • Ischemic stroke; or
  • Unstable angina.

Repeat courses of ECP will be considered medically necessary for individuals with chronic stable angina if ALL of the following criteria are met:

  • Individual meets medical necessity criteria for ECP; and
  • Prior ECP has resulted in a sustained improvement in symptoms with:
    • A significant (greater than 25%) reduction in frequency of angina symptoms; or
    • Improvement by one or more angina classes; and
    • Three (3) or more months has elapsed from the prior ECP treatment; and
    • Individual has shown documented compliance with treatment in the past.

Repeat courses of ECP not meeting the criteria as indicated in this policy is considered not medically necessary.

Hydraulic versions of ECP devices are non-covered due to the limited use of the device.

Canadian Cardiovascular Society Grading of Angina Pectoris:

Class

Description of Angina severity

0

Asymptomatic Angina 

Mild myocardial ischemia with no symptoms.

I

Angina only with strenuous exertion

Presence of angina during strenuous, rapid, or prolonged ordinary activity (walking or climbing the stairs).

II

Angina with moderate exertion

Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.

III

Angina with mild exertion

Having difficulties walking one or two blocks or climbing one flight of stairs at normal pace and conditions.

IV

Angina at rest

No exertion needed to trigger angina.

G0166

 

 

 

 

 

 


External cardiac assist (92971), ECG rhythm strip and report (93040 or 93041), and plethysmography (93922 or 93923), or other monitoring tests for examining the effects of this treatment are not separately reimbursable on the same day as ECP , unless they occur in a clinical setting not connected with the delivery of the ECP service.

93040

93041

93922

93923

92971

 

 


Professional Statements and Societal Positions Guidelines

American College of Cardiology Foundation / American Heart Association-2013

The most recent guidelines of the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) include the following recommendations for the treatment of CS:

  • Class I
    • Emergency revascularization with either PCI or CABG is recommended in suitable patients with CS due to pump failure after STEMI irrespective of the time delay from MI onset. (Level of Evidence: B).
    • Cardiac catheterization and coronary angiography with intent to perform revascularization should be performed after STEMI in patients with CS that develops after initial presentation. (Level of Evidence: B).
    • PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and CS. (Level of Evidence: B)
    • Urgent CABG is indicated in patients with STEMI and coronary anatomy amenable to PCI who have ongoing or recurrent CS. (Level of Evidence: B).
    • In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and CS who are unsuitable candidates for either PCI or CABG. (Level of Evidence: B).
  • Class IIa
    • The use of IABP counterpulsation can be useful for patients with CS after STEMI who do not quickly stabilize with pharmacologic therapy. (Level of Evidence: B).
  • Class IIb
    • Alternative LVADs for circulatory support may be considered in patients with refractory CS. (Level of Evidence: C).

AACF/AHA-2013

Guidelines for the management of heart failure state that nondurable mechanical circulatory support with percutaneous and extracorporeal VADs is reasonable as a bridge to recovery or bridge to decision for carefully selected patients with heart failure with reduced ejection fraction who have acute, profound hemodynamic compromise (Level of Evidence: B).


Covered Diagnosis Codes for G0166

I20.1

I20.2

I20.81

I20.89

I20.9

I25.111

I25.112

I25.118

I25.119

I25.701

I25.702

I25.708

I25.709

I25.711

I25.712

I25.718

I25.719

I25.721

I25.722

I25.728

I25.729

I25.731

I25.732

I25.738

I25.739

I25.751

I25.752

I25.758

I25.759

I25.761

I25.762

I25.768

I25.769

I25.791

I25.792

I25.798

I25.799

 

 

 

 

 


Place of Service: Outpatient

External Counterpulsation (ECP) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.