CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Enhanced External Counterpulsation (EECP) Coverage Criteria

Coverage guidelines for outpatient enhanced external counterpulsation (EECP) for BlueCHiP for Medicare and Commercial products offered by Blue Cross & Blue Shield of Rhode Island, describing when EECP is covered or considered not medically necessary.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyEnhanced External Counterpulsation (EECP) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateDec 1, 2014

Next Review Date

Key ActionFor Medicare members, ensure a cardiologist or cardiothoracic surgeon documents that the patient has disabling angina and is not readily amenable to surgical intervention per CMS NCD criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

35Typical full course

MixedCoverage stance

2019-05-21Last updated

2006CMS NCD

Coverage Criteria

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BlueCHiP for Medicare coverage criteria

Covered when ALL of the following CMS national coverage determination conditions are met:

Medicare NCD criteria: Patient has disabling angina and, in the opinion of a cardiologist or cardiothoracic surgeon, is not readily amenable to surgical intervention (permitting any of: inoperable or high operative risk; coronary anatomy not amenable to revascularization; or comorbid states creating excessive risk)

Based on CMS national coverage determination

Commercial products – Not medically necessary

EECP used in outpatient treatment is considered not medically necessary for Commercial products for all indications due to insufficient evidence.

Commercial product stance: EECP is not medically necessary for chronic stable angina pectoris, heart failure, erectile dysfunction, ischemic stroke, and other indications because peer-reviewed scientific literature is insufficient to demonstrate effectiveness

RCTs and systematic reviews are inconclusive; observational studies add little due to confounding and placebo effect

For Commercial products, outpatient enhanced external counterpulsation (EECP) is not medically necessary. This determination applies to all indications, including but not limited to treatment of chronic stable angina pectoris, heart failure, erectile dysfunction, and ischemic stroke, because the available peer‑reviewed scientific literature is insufficient to demonstrate that the procedure is effective.

Provider Actions & Requirements

Prior Authorization

Prior authorization is not applicable for this policy.

Documentation Required

Medicare clinical assessment requirement

Medicare coverage requires a physician (cardiologist or cardiothoracic surgeon) assessment that the patient has disabling angina and is not readily amenable to surgical intervention (e.g., percutaneous transluminal coronary angioplasty or cardiac bypass) because: 1) the condition is inoperable or at high risk of operative complications or post-operative failure; 2) the coronary anatomy is not readily amenable to such procedures; or 3) co-morbid states create excessive risk.

Documentation Required

EECP treatment course documentation

Typical full course consists of 35 one-hour treatments, which may be offered once or twice daily, usually 5 days a week. Document device use and monitoring details including timed sequential cuff inflation, finger plethysmography, continuous ECG triggering, and any pulse oximetry readings.

Denial Risk

Commercial product denial risk

For Commercial products, outpatient EECP is considered not medically necessary for all indications (including chronic stable angina, heart failure, erectile dysfunction, or ischemic stroke) due to insufficient peer‑reviewed evidence to demonstrate effectiveness; expect denial for these indications.

Background

Enhanced External Counterpulsation (EECP) is a noninvasive therapy that uses timed, sequential inflation of pressure cuffs applied to the calves, thighs, and buttocks to augment diastolic pressure, reduce left ventricular afterload, and increase venous return. Typical treatment courses and device operation details should be documented when therapies are provided.

Definitions

Enhanced External Counterpulsation (EECP) — procedure definition and method

ProcedureNoninvasive therapy using timed, sequential inflation of pressure cuffs on the calves, thighs, and buttocks to augment diastolic pressure, decrease left ventricular afterload, and increase venous return

MechanismAugmentation of diastolic pressure displaces blood backward into the coronary arteries during diastole to increase coronary perfusion pressure, potentially enhancing collateral development and coronary flow

Typical treatment courseA full course usually consists of 35 one-hour treatments, offered once or twice daily, typically 5 days per week

Procedure componentsIncludes use of the EECP device, finger plethysmography to follow blood flow, continuous ECG triggering for inflation/deflation, and optional pulse oximetry to measure oxygen saturation before and after treatment

Disabling angina (per CMS NCD) — definition and criteria

Definition (CMS NCD)Angina in patients diagnosed with disabling angina who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention

Reasons patient may be not amenable to surgeryTheir condition is inoperable or at high risk of operative complications or post-operative failure

Coronary anatomy criterionCoronary anatomy is not readily amenable to percutaneous transluminal coronary angioplasty or cardiac bypass

Comorbid states criterionPresence of co-morbid states which create excessive operative risk