Body Surface Potential Mapping
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This policy governs the coverage stance for body surface potential mapping (BSPM) procedures and related CPT/HCPCS/ICD-10 codes for Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Experimental / Investigational Indications
Experimental/Investigational Indications
Aetna considers BSPM experimental and investigational for the following indications because effectiveness has not been established:
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
Derived from multiple background sections; preliminary evidence only
Coding — CPT, HCPCS, and ICD-10 Codes
| 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. |
| 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. |
| 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). |
| I00-I52 | Heart disease |
| No codes listed |
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 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 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
Provider Authorization
No explicit provider authorization or additional prior authorization requirements are specified in this portion of the document.
- Provider authorization: Not specified
Background — What is Body Surface Potential Mapping (BSPM)
Body surface potential mapping is an electrophysiologic technique that records cardiac electrical activity from a much larger surface area than the conventional 12-lead ECG by using many more electrodes on the torso—typically 64 up to approximately 120 electrodes—to generate detailed surface potential maps and three-dimensional representations of cardiac electrical activation.
Definitions and Key Terms
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