Anthem Blue Cross Connecticut CG-MED-86 Enhanced External Counterpulsation in the Outpatient Setting Form

This document addresses the use of enhanced external counterpulsation (EECP) in the outpatient setting. EECP is used to treat disabling, chronic, stable angina in individuals refractive to optimal medical therapy and not readily amenable to surgical intervention.

Clinical Indications

Medically Necessary:

1. A single* course of enhanced external counterpulsation (EECP) is considered medically necessary for individuals when the criteria below are met:
   1. Disabling, chronic, stable angina, (defined as Class III or Class IV Canadian Cardiovascular Society Classification [see definition section] angina or equivalent); and
   2. Individuals refractive to optimal medical therapy and not readily amenable to surgical intervention such as percutaneous transluminal coronary angioplasty (PTCA) or cardiac bypass due to any of the following:
      1. Condition is inoperable; or
      2. High risk of operative complications or postoperative failure; or
      3. Coronary anatomy is not readily amenable to such procedures;
         and
   3. None of the following comorbid conditions or contraindications that would result in excessive risk are present, including but not limited to the following:
      1. Aortic insufficiency (regurgitation might prevent diastolic augmentation); or,
      2. Arrhythmias such as atrial fibrillation, atrial flutter, ventricular tachycardia, and frequent premature ventricular beats (might interfere with the device’s triggering mechanism); or
      3. Uncontrolled bleeding diatheses; or
      4. Severe heart failure; or
      5. Deep vein thrombosis, varicosities, or stasis ulcers; or
      6. Peripheral vascular disease, phlebitis (increased risk of thromboembolus); or
      7. Severe hypertension (treatment could produce diastolic blood pressure above acceptable limits); or
      8. Stroke.

Note: *A single course of treatment consists of a total of 35 hours of EECP; treatment is administered for one to two hours daily, 5 days a week, for approximately 3½ to 7 weeks.

2. A repeat course of EECP therapy is considered medically necessary in individuals who met the criteria in section (I) above, have chronic stable angina and who have objectively demonstrated a response to EECP. This would include those individuals who demonstrate one or more of the following:
   1. Early improvement in radionuclide stress perfusion imaging compared to a pre-EECP baseline; or
   2. Reduction in antianginal medication use; or
   3. Improvement in exercise tolerance.

Not Medically Necessary:

The use of EECP is considered not medically necessary when the criteria above are not met and for all other indications.