CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Cardiointegram

Commercial products only: policy addresses medical necessity and coverage determination for Cardiointegram (CIG)/Omnicardiogram as a diagnostic technique to detect abnormalities in standard 12-lead ECG for individuals at risk of cardiac ischemia. Medicare Advantage plans are directed to related policies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Cardiointegram

Policy CodePolicy N/A

Change TypeClarified scope to Commercial Products

Effective DateFeb 6, 2010

Next Review Date

Key ActionClaims billed under HCPCS code S9025 (Omnicardiogram/cardiointegram) for Commercial Products are considered not medically necessary and are subject to denial; verify member-specific benefits.

SourceLink

POLICY UPDATE CHANGES

Policy applies to Commercial Products only; Medicare Advantage plans referenced to related policies.

1HCPCS code listed as not medically necessary

Commercial onlyPlan scope

Coverage Summary

Scope: Commercial products only — policy addresses medical necessity and coverage determination for Cardiointegram (CIG) / Omnicardiogram as a diagnostic technique to detect abnormalities in standard 12-lead ECG for individuals at risk of cardiac ischemia. Medicare Advantage plans are directed to related policies.

Coverage stance: Not medically necessary (not_covered_cosmetic) for Commercial Products; see Related Policies for Medicare Advantage/NCD references.

Medical-Necessity Determination

Medical Necessity Determination

Coverage decision for Commercial Products:

Medical Necessity Determination: Cardiointegram (CIG) / Omnicardiogram is considered not medically necessary for Commercial Products because the evidence is insufficient to determine the effects of the technology on health outcomes

Policy applies to Commercial Products only; see Related Policies for Medicare Advantage Plans.

Not Covered / Investigational

Policy stance: Cardiointegram (CIG) / Omnicardiogram is considered not medically necessary / investigational as a diagnostic tool because the evidence is insufficient to determine its effects on health outcomes.

Evidence summary: multiple older published studies are cited but do not provide sufficient evidence to support efficacy as a diagnostic alternative to stress testing; therefore the technology is considered investigational for this indication.

CMS NCD: the policy references the CMS NCD for cardiointegram (CIG) as an alternative to stress test or thallium stress test (last modified April 23, 2009), reinforcing the investigational/not-covered status.

Not Medically Necessary

Not Medically Necessary: Cardiointegram (CIG) / Omnicardiogram (HCPCS S9025) is not medically necessary for Commercial Products because the evidence is insufficient to determine the effects of the technology on health outcomes

Claims billed under HCPCS S9025 for Commercial Products are subject to denial; benefits may vary by contract.

Provider Actions

Denial Risk

Claims for Cardiointegram (S9025) for Commercial Members

Claims billed under HCPCS code S9025 (Omnicardiogram/cardiointegram) for Commercial Products are considered not medically necessary and are subject to denial. Benefits may vary by contract, so verify the member-specific Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.

S9025
Verify member-specific Benefit Booklet/Evidence of Coverage/Subscriber Agreement

Documentation Required

Refer to Member Benefit Documents

Providers must refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific not medically necessary benefits/coverage and should contact the provider call center for member-specific information.

Background & Evidence

Background: A Cardiointegram device consists of a microcomputer that receives output from a standard electrocardiogram (EKG) and transforms it to produce a graphic representation of heart electrophysiologic signals. It may be proposed as a substitute for exercise tolerance testing with thallium imaging when a resting EKG is inadequate.

Clinical evidence and policy conclusion: Cardiointegram is intended to detect abnormalities not identifiable by routine ECG interpretation in patients at risk of cardiac ischemia; however, the evidence is insufficient to support conclusions regarding its efficacy as a diagnostic tool, and it is therefore considered not medically necessary for Commercial Products.

Published evidence: Older studies (e.g., Angiology 1988; Circulation 1975; J Electrocardiol 1986) are cited but do not establish sufficient evidence of clinical benefit.

Source	Summary
CMS NCD
Published studies

Cardiointegram (CIG) / Omnicardiogram: A technique/device that transforms standard 12-lead ECG output via a microcomputer to produce a graphic representation of heart electrophysiologic signals intended to detect abnormalities not identifiable by routine ECG interpretation.

Type	Name	Effective Date	Notes
NCD
NCD for cardiointegram (CIG) as an alternative to stress test or thallium stress test
2009-04-23
Medicare Advantage plans are referenced to related policies; see Related Policies section