External Counterpulsation (ECP)

Section: Diagnostic Medical
Effective Date: March 01, 2020
Revised Date: May 19, 2020
Last Reviewed: May 19, 2020

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.

Criteria


ECP may be considered medically necessary using an FDA approved device when BOTH of the following are met:

  • Theindividual has been diagnosed with disabling chronic stable angina (Class III or Class IV, New York Heart Association Functional Classification of Cardiac Disability); 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:
    • Their condition is inoperable, or at high risk of operative complications or post-operative failure; or
    • Their coronary anatomy is not readily amenable to such procedures; or
    • They have co-morbid states which create excessive risk.

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:

  • Unstable angina
  • Acute myocardial infarction
  • Cardiogenic shock
  • Erectile dysfunction
  • Ischemic stroke

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:

  • 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.

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.

Procedure Codes

G0166

Diagnosis Codes

 

I20.1 I20.8 I20.9 I25.111 I25.118 I25.119 I25.701
I25.708 I25.709 I25.711 I25.718 I25.719 I25.721 I25.728
I25.729 I25.731 I25.738 I25.739 I25.751 I25.758 I25.759
I25.761 I25.768 I25.769 I25.791 I25.798 I25.799

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

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

Links

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.