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

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.