CurrentAetnaPolicy 0705

Body Surface Potential Mapping

This policy governs the coverage stance for body surface potential mapping (BSPM) procedures and related CPT/HCPCS/ICD-10 codes for Aetna members.

Policy Summary

PayerAetna

PolicyBody Surface Potential Mapping

Policy CodePolicy 0705

Change TypeNo material change

Effective DateJun 7, 2005

Next Review DateAug 8, 2024

Key ActionWhen submitting claims, include procedure code(s) describing BSPM or related device interrogation/programming and supporting clinical documentation describing the indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64-120electrodes (typical)

Experimental/Investigationalcoverage stance

PRIME‑ECGexample system

66CRT study size

80leads in OCCULT‑MI study

Coverage Criteria — Experimental / Investigational Indications

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Experimental/Investigational Indications

Aetna considers BSPM experimental and investigational for the following indications because effectiveness has not been established:

Listed indications considered experimental/investigational: 1. Evaluation of acute coronary syndromes (e.g., acute cardiac ischemia and myocardial infarction); 2. Evaluation of atrial fibrillation; 3. Evaluation of Brugada syndrome; 4. Guidance of atrial fibrillation ablation; 5. Prediction of response in cardiac resynchronization therapy.

Not an all-inclusive list; effectiveness not established

Aetna considers body surface potential mapping (BSPM) experimental and investigational for the following indications because effectiveness has not been established: 1) evaluation of acute coronary syndromes (for example, acute cardiac ischemia and myocardial infarction); 2) evaluation of atrial fibrillation; 3) evaluation of Brugada syndrome; 4) guidance of atrial fibrillation ablation; and 5) prediction of response to cardiac resynchronization therapy (CRT). Services for these indications may be denied as experimental and investigational.

UpToDate reviews cited in the evidence summary do not mention body surface potential mapping as a management tool for atrial fibrillation ablation or for Brugada syndrome; specifically, multiple UpToDate reviews on catheter and surgical ablation for atrial fibrillation do not reference BSPM for guiding AF ablation, and an UpToDate review on Brugada syndrome does not mention body surface mapping as a management strategy.

Available studies report preliminary findings suggesting potential roles for BSPM (for example, complex network metrics to predict atrial fibrillation recurrence and BSPM-derived metrics to predict CRT response), but the policy notes these observations are preliminary and explicitly states that such findings need validation in well-designed studies before routine clinical use can be supported.

Evidence observations

Summary of clinical findings and limitations from cited studies

Evidence observations: Small observational and pilot studies report potential applications of BSPM including: guidance of atrial fibrillation ablation (UpToDate reviews do not mention BSPM for AF ablation), mapping activation patterns in Brugada syndrome using multi‑lead recordings, prediction of CRT response via SDAT (standard deviation of activation times) with reported SDAT >=35 ms and >=10% SDAT improvement associated with greater EF/LVESV changes, detection of ischemia during exercise with HR‑BSPM showing modestly higher sensitivity/specificity than standard 12‑lead ECG, and exploratory complex‑network metrics from BSPM that may predict AF recurrence; however, these findings are preliminary, limited by small sample sizes and observational designs, and require validation in well‑designed studies.

Derived from multiple background sections; preliminary evidence only

Coding — CPT, HCPCS, and ICD-10 Codes

CPT codes not covered for CPB-listed indicationsCPTNot Covered

0695T	Body surface–activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of implant or replacement.
0696T	Body surface–activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of follow-up interrogation or programming device evaluation.

Other related CPT codes referencedCPT

33208	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular.
33214	Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator).
33224	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator).
33225	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure).
33229	Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system.
33249	Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber.
33263
33264	Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator.
93000-93278	Cardiography.
93281-93284	Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional.

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Related HCPCS codesHCPCS

C7537	Insertion of new or replacement of permanent pacemaker with atrial transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable debribrillator or pacemake pulse generator (eg, for upgrade to dual chamber system).
C7538	Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defribrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system).
C7539	Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system).
C7540	Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system).

ICD-10 codes not covered for CPB-listed indicationsICD-10Not Covered

I00-I52

Heart disease

No codes listed in this document sectionmixed

No codes listed

SDAT threshold

SDAT threshold>= 35 ms predicts changes in EF after CRT

Study sample size66 patients (Gage et al., 2017)

Electrode count in CRT maps53 anterior and posterior electrodes used to construct body surface isochronal maps

SDAT percent change

SDAT percent change associated with response>= 10% improvement in SDAT associated with greater changes in EF and LVESV after CRT

EF change with >=10% SDAT improvement11 ± 9 units versus 4 ± 9 units (p = 0.010)

LVESV change with >=10% SDAT improvement-33% ± 26% versus -6% ± 34% (p = 0.001)

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior authorization not specified in this portion of the policy. The document does not list any specific CPT or HCPCS codes that require prior authorization for body surface potential mapping procedures.

Prior authorization: Not specified

Denial Risk

Denial Risk for Listed Indications

Services billed for body surface potential mapping (BSPM) for the indications listed in this policy (e.g., evaluation of acute coronary syndromes, atrial fibrillation, Brugada syndrome, guidance of atrial fibrillation ablation, prediction of response in cardiac resynchronization therapy) are considered experimental and investigational and may be denied.

Denial risk: BSPM for listed indications may be denied as experimental/investigational

Documentation Required

Documentation and Claim Guidance

No specific documentation requirements are stated in this portion of the policy. When submitting claims, include applicable procedure code(s) and supporting documentation (e.g., clinical indication, reports) as appropriate to substantiate medical necessity.

Documentation: No specific documentation requirements stated
Claim guidance: Include procedure code(s) and supporting documentation when submitting claims

Step Therapy

No step therapy requirements are described in this portion of the policy.

Step therapy: None specified

Note

Provider Authorization

No explicit provider authorization or additional prior authorization requirements are specified in this portion of the document.

Provider authorization: Not specified

Definitions and Key Terms

Body surface potential mapping (BSPM)

DefinitionElectrophysiologic technique using multiple torso electrodes (typically 64 up to ~120) to record cardiac electrical activity across a larger surface area than the standard 12‑lead ECG, generating comprehensive 3‑dimensional surface potential maps.

Typical electrode countsCommonly 64 or more electrodes; may use up to ~120 electrodes.

Primary uses investigatedDetection/localization of ischemia, infarct sizing, arrhythmia mapping, guidance of ablation, and CRT response assessment.

PRIME‑ECG

Example systemPRIME‑ECG — a BSPM system cleared by the FDA through the 510(k) process (Meridian Medical Technologies / Heartscape Technologies).

Regulatory statusIdentified among devices cleared for marketing by the FDA in technology assessments; PRIME‑ECG commercially available and 510(k) cleared.

Role in evidence basePRIME‑ECG featured in assessments as demonstrating proof of concept but requiring further research to define clinical utility.

SDAT (standard deviation of activation times)

DefinitionStandard deviation of activation times (SDAT) — a metric derived from BSPM that quantifies electrical dyssynchrony across body surface activation times.

Clinical relevanceSDAT has been reported to predict response to cardiac resynchronization therapy (CRT) better than QRS duration in studied cohorts.

Association with outcomesHigher SDAT values and reductions in SDAT after pacing correlated with greater improvements in left ventricular ejection fraction and reductions in LVESV.

HR‑BSPM (high‑resolution BSPM)

DefinitionHigh‑resolution body surface potential mapping (HR‑BSPM) — a multi‑lead BSPM configuration (e.g., 67 leads) used during exercise testing to detect ischemic changes not captured by standard 12‑lead ECG positions.

Electrode count example67‑lead HR‑BSPM used in exercise studies comparing to 12‑lead ECG.

Diagnostic performanceHR‑BSPM parameters (ΔST60 and δT) showed higher sensitivity/specificity (e.g., 70/69% for ΔST60) than standard 12‑lead ECG in one study.

OpenPayer

Body Surface Potential Mapping

Coverage Criteria — Experimental / Investigational Indications

Coding — CPT, HCPCS, and ICD-10 Codes

Provider Actions, Authorization, and Documentation

Background — What is Body Surface Potential Mapping (BSPM)

Definitions and Key Terms