Impedance Cardiography in Hypertension

Policy ID: M-83-004

Section: Diagnostic Medical

Effective Date: November 01, 2019

Revised Date: November 03, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective January 01, 2024. Click the Archive tab above for more information.

Policy ID: M-83-004

Effective Date: November 01, 2019

Revised Date: November 03, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Archived Date: January 01, 2024

Applies To: Commercial and Medicaid Expansion

Description

Impedance cardiography (ICG), also referred to as thoracic electrical bioimpedance (TEB), is a noninvasive means of determining cardiac output in which the stroke volume of each cardiac contraction is determined by measuring beat-to-beat changes in the electrical impedance of the chest and neck.

Criteria

ICG may be considered medically necessary for individuals with drug-resistant hypertension when BOTH of the following criteria are met:

Unable to attain target clinic blood pressure of lower than 140/90; and
Taking three (3) classes of antihypertensive medications, including a diuretic.

ICG for all other types of HTN may be considered experimental/investigational and therefore non-covered due to lack of supporting published peer reviewed literature.

Procedure Code

93701

Diagnosis Codes

G93.2

H40.051

H40.052

H40.053

H40.059

I10

I11.0

I11.9

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

I15.0

I15.1

I15.2

I15.8

I15.9

I16.0

I16.1

I16.9

I1A.0

I27.0

I27.20

I27.21

I27.22

I27.23

I27.24

I27.29

I67.4

I87.301

I87.302

I87.303

I87.309

I87.311

I87.312

I87.313

I87.319

I87.321

I87.322

I87.323

I87.329

I87.331

I87.332

I87.333

I87.339

I87.391

I87.392

I87.393

I87.399

I97.3

K76.6

O10.011

O10.012

O10.013

O10.019

O10.02

O10.03

O10.111

O10.112

O10.113

O10.119

O10.12

O10.13

O10.211

O10.212

O10.213

O10.219

O10.22

O10.23

O10.311

O10.312

O10.313

O10.319

O10.32

O10.33

O10.411

O10.412

O10.413

O10.419

O10.42

O10.43

O10.911

O10.912

O10.913

O10.919

O10.92

O10.93

O11.1

O11.2

O11.3

O11.4

O11.5

O11.9

O13.1

O13.2

O13.3

O13.4

O13.5

O13.9

O16.1

O16.2

O16.3

O16.4

O16.5

O16.9

O19.93

P29.2

P29.30

R03.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New Policy for ND

Internal Medical Policy Committee 9-21-2020 Annual Review - No changes

Internal Medical Policy Committee 9-12-2023 Annual Review

Removed duplicate diagnosis code I27.0

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

Added diagnosis code I1A.0

Internal Medical Policy Committee 11-15-2023 Archiving - Effective January 01, 2024

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.

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