Enhanced External Counterpulsation

Medical Policy: 02.02.02 
Original Effective Date: June 2000 
Reviewed: January 2012 
Revised:  

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

EECP is a non-invasive outpatient treatment for coronary artery disease refractory to medical and/or surgical treatment. It involves the sequential compression (inflation/deflation) of cuffs wrapped around the patient's calves, thighs, and buttocks. The intention is to increase diastolic aortic pressure, thereby increasing coronary perfusion pressure possibly by enhancing the development of coronary collateral circulation and reducing the workload of the heart. The treatment usually consists of 35 hours of EECP therapy. The treatment is administered as one or two hour sessions daily, four to five days per week.

While EECP has been primarily researched as a treatment of chronic stable angina, it has also been used in patients with congestive heart failure.

Canadian Cardiovascular Society grading of angina pectoris:

Grade Description

• Grade I – Ordinary physical activity does not cause angina, such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation

• Grade II – Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions

• Grade III – Marked limitation of ordinary physical activity. Walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace

• Grade IV– Inability to carry on any physical activity without discomfort,anginal syndrome may be present at rest

Reference: Campeau Lucien. Grading of angina pectoris. Circulation 1976;54:5223

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Prior Approval: 

Not applicable

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Policy: 

Up to 35 treatment sessions of EECP may be considered medically necessary when the following conditions have been met:

• A diagnosis of disabling angina has been established  (class III or IV; Canadian Cardiovascular Society Angina Classification, or equivalent classification).
• In the opinion of a cardiologist or cardiothoracic surgeon, the patient's condition is not readily amenable to surgical intervention such as PTCA or CABG.

EECP is considered investigational for any condition not listed above, including, but not limited to congestive heart failure, acute myocardial infarction and cardiogenic shock because there is inadequate scientific evidence to permit conclusions about the efficacy of this treatment for conditions other than disabling angina as specified in the covered services section above.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• G0166 external counterpulsation, per treatment session. 

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Selected References: 

• The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
• A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), who assist Wellmark in the development of medical policies. The group is comprised of a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
• Campeau Lucien. Grading of angina pectoris. Circulation 1976;54:5223 Available on the Canadian Cardiovascular Society Website at www.ccs.ca 
• Medicare coverage section 35-74.
• Soran O, Crawford LE, Schneider VM, Feldman AM. Enhanced External counterpulsation in the Management of Patients with Cardiovascular Disease. Clinical Cardiology 1999; 22: 173-178.
• Stys TP, Lawson MW, Hui JC, Fleishman B, Manzo K, Stroeck JE, Tartaglia J, Ramasamy S, Suwita R, Zheng ZS, Liang H, Werner D. Effects of enhanced external counterpulsation on stress radionuclide coronary perfusion and exercise capacity in chronic stable angina pectoris. American Journal of Cardiology; 2002 Apr 1; 89(7): 822-4.
• Medical Advisory Panel Meeting June 6, 2002. External Counterpulsation for treatment of chronic stable angina pectoris. TEC Bulletin July 8, 2002;19(2):6-9.
• Arora RR. Et.al. The multicenter study of enhanced external counterpulsation (MUST_EECP): Effect of EECP on exercise-induced myocardial ischemia and anginal episodes. Journal of American College of Cardiology 1999; 33(7): 1833-1840.
• Lawson WE, Hui JCK, Cohn PF. Long-term prognosis of patients with angina treated with enhanced external counterpulsation: Five-years follow-up study. Clinical Cardiology 2000;23:254-258.
• Lawson WE, Silver MA, et al. Angina patients with diastolic versus systolic heart failure demonstrate comparable immediate and one-year benefit from enhanced external counterpulsation. J Card Fail. 2005 Feb;11(1):61-6. Abstract viewed on line.
• Vijayaraghavan K, Santora L, et al. New graduated pressure regimen for external counterpulsation reduces mortality and improves outcomes in congestive heart failure: a report from the Cardiomedics External Counterpulsation Patient Registry. Congest Heart Fail. 2005 May-Jun;11(3):147-52. Abstract viewed on line.
• Soran O. Kennard ED. et al. Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry). Am J Cardiol. 2006 Jan 1;97(1):17-20.
• Michaels AD, Raisinghani A, et al. The effects of enhanced external counterpulsation on myocardial perfusion in patients with stable angina: a multicenter radionuclide study. Am Heart J. 2005 Nov;150(5):1066-73.
• Manchanda A, Soran O. Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. J Am Coll Cardiol. 2007 Oct 16;50(16):1523-31.
• Estahbanaty G, Samiei N, Maleki M et al. Echocardiographic characteristics including tissue Doppler imaging after enhanced external counterpulsation therapy. Am Heart Hosp J 2007 Fall;5(4):241-6.
• McCullough PA, Henry TD, Kennard ED et al. Residual high-grade angina after enhanced external counterpulsation therapy. Cardiovasc Revasc Med. 2007 Jul-Sep;8(3):161-5.
• Sajja V, Dod H, Beto R et al. An Analysis of the efficacy and safety of enhanced external counterpulsation at West Virginia University Hospitals. W V Med J. 2007 May-Jun;103(3):10-2.
• Loh PH, Cleland JG, Louis AA, Kennard ED, Cook JF, et al. Enhanced external counterpulsation in the treatment of chronic refractory angina: a long-term follow-up outcome from the International Enhanced External Counterpulsation Patient Registry. Clin Cardiol. 2008 Apr;31(4):159-64.
• McKenna C, McDaid C, Suekarran S, Hawkins N, Claxton K, Light K, et al. Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis. Health Technol Assess 2009;13(5).
• Zipes DP, editor. Braunwald’s Heart Disease. A textbook of Cardiovascular Medicine. 9^th ed. Philadelphia, PA: Saunders; 2011 Ch 57.
• National Institute for Health and Clinical Excellence (NICE). Management of stable angina. Clinical Guideline 126. London, UK: NICE; July 2011.  

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Policy History: 

Date                                        Reason                               Action

January 2011                          Annual review                    Policy renewed

January 2012                          Annual review                    Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.