External Counterpulsation

Policy ID: M-52-027

Section: Diagnostic Medical

Effective Date: March 01, 2022

Revised Date: December 26, 2023

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

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.

Criteria

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:
- 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

Asymptomatic Angina

Mild myocardial ischemia with no symptoms.

Angina only with strenuous exertion

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

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.

Angina at rest

No exertion needed to trigger angina.

Procedure Codes

G0166

Diagnosis Codes

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

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 individuals 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 individuals 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 individuals with suitable anatomy and CS. (Level of Evidence: B)
- Urgent CABG is indicated in individuals 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 individuals 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 individuals 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 individuals 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 individuals with heart failure with reduced ejection fraction who have acute, profound hemodynamic compromise (Level of Evidence: B).

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Revision

Added erectile dysfunction and ischemic stroke as E/I.

Internal Medical Policy Committee 5-19-2020 Revision

Updated language from PTCA to coronary intervention;
Removed reimbursement language

Internal Medical Policy Committee 3-17-2021 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-22-2021 Revision

Updated language throughout policy.

Internal Medical Policy Committee 7-21-2022 Revision

Updated criteria

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Added Diagnosis codes I20.2; I 25.112; I25.702; I25.712; I25.722; I25.732; I25.752; I25.762; I25.792

Internal Medical Policy Committee 11-15-2023 - Effective October 01, 2023

Added Diagnosis codes I20.81 and I20.89 to Procedure code G0166.
Removed Diagnosis code I20.8 from Procedure code G0166.

Internal Medical Policy Committee 1-16-2024 - Revision- Effective March 04, 2024

Minor Grammatical changes
Updated references

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-52-026