Criteria
Coverage is subject to the specific terms of the member's benefit plan.
ECP may be considered medically necessary using the 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 Cardiovascular Society Grading in Angina Pectoris; 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 is considered not medically necessary.
- 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:
- Asignificant (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.
|
Procedure Code
