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.
ECP may be considered medically necessary using an FDA approved device when BOTH of the following are met:
A full course of therapy usually consists of up to 35 one (1) hour treatments, which may be offered once (1) or twice (2) daily, usually five (5) days per week.
This procedure must be done under direct supervision of a physician.
ECP for any other indication including, but not limited to, the following is considered not medically necessary:
Documentation in the medical record must contain a history and physical pertinent to the indications of this policy and be available upon request.
Repeat courses of ECP will be considered medically necessary for individuals with chronic stable angina if ALL of the following criteria are met:
Repeat courses of ECP for any other indication is considered not medically necessary.
Hydraulic versions of ECP devices are non-covered due to the limited use of the device.
New York Heart Association Functional Classification of Cardiac Disability:
|Class I||Individuals with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.|
|Class II||Individuals with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.|
|Class III||Individuals with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.|
|ClassIV||Individuals with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased|
Source: American Heart Association, Classes of Heart Failure. 2017.
Internal Medical Policy Committee 1-22-2020 added erectile dysfunction and ischemic stroke as E/I.
Internal Medical Policy Committee 5-19-2020 updated language from PTCA to coronary interventin; removed reimbursement language
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.