Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

External Counterpulsation (ECP) and Enhanced External Counterpulsation (EECP) are techniques of non-invasive treatment for angina pectoris. These treatments will be allowed if they meet medical necessity criteria.

1)    Coverage for External Counterpulsation for angina is limited to a diagnosis of stable angina pectoris (I20.1-I20.9, I25.111-I25.119, I25.701-I25.709, I25.711-I25.719, I25.721-I25.729, I25.731-I25.739, I25.751-I25.759, I25.761-I25.769, I25.791-I25.799). 

2)    The member must demonstrate all of the following:

a)    Coronary artery disease diagnosed by coronary artery catheterization (at any time in the past)

b)    Diagnosis of disabling angina (New York Heart Association Class III or Class IV)

c)     Unsuitable for either PTCA or CABG due to:

i)       a condition that is inoperable; OR

ii)     the patient is at high risk of operative complications or post-operative failure; OR

iii)    the coronary anatomy is not readily amenable to such procedures; OR

iv)   there are co-morbid states which create excessive risk.

3)    A full course of therapy usually consists of 35 one-hour treatments, once or twice a day, five days a week, using a pneumatic device. Hydraulic versions of the device are not covered.

4)    Correct billing involves the use of code G0166.  Evaluation and Management codes (99201-99215) will not be allowed on the same dates as G0166.

Codes Used In This BI:

G0166                    External Counterpulsation

External Counterpulsation (ECP) or Enhanced External Counterpulsation (EECP) is a non-invasive outpatient treatment for coronary artery disease refractory to medical and/or surgical therapy.  It works by rapidly inflating pneumatic trousers that in turn increase diastolic blood pressure.  This increase in diastolic blood pressure improves myocardial perfusion.  During systole the trousers deflate, reducing afterload and improving cardiac workload and oxygen requirements.  There is evidence that most patients experience increased time until the onset of ischemia, increased exercise tolerance, and a reduction in the number and severity of angina episodes that last beyond the treatment phase.  Some patients become symptom free for several months to years.  Although these and similar devices are cleared by the FDA for use in treating a variety of conditions, including stable or unstable angina pectoris, acute myocardial infarction, and cardiogenic shock, only the use for stable angina pectoris has sufficient demonstrated evidence of medical effectiveness.  This procedure must be done under the direct supervision of a physician.

The Stages of Heart Failure – NYHA Classification

In order to determine the best course of therapy, physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient`s quality of life.

Class     Patient Symptoms

Class     I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Class     II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class     III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
Class     IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
 

HCFA Coverage Issues Manual, Medical Procedures, #35-74 Enhanced Counterpulsation for Severe Angina, page 43. 

http://www.hcfa.gov/pubforms/06_cim/ci35.htm

Hayes Manual, ENHA0701.13, October 11, 1999

Hayes: External Counterpulsation. November 2002.

Medicare Claims Processing Manual 100-4, 32, 130

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.