Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE:11|21|2017 POLICY LAST UPDATED: 03|15|2023 OVERVIEW The electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect underlying heart conditions by measuring the electrical activity of the heart. By positioning leads (electrical sensing devices) on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG. MEDICAL CRITERIA Not applicable. PRIOR AUTHORIZATION
Not applicable. POLICY STATEMENT Medicare Advantage Plans and Commercial Products EKG services are covered diagnostic tests when there are documented signs and symptoms or other clinical indications for providing the service.
EKG services should not routinely be performed as part of a preventive exam unless the member has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test. Note: Blue Cross & Blue Shield of Rhode Island (BCBSRI) reserves the right to audit claims and to recoup any money paid to providers for claims ineligible for payment. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable diagnostic test benefits/coverage. BACKGROUND Recent guidelines from the U.S. Preventive Services Task Force (USPSTF) (2011), the American Academy of Family Physicians (AAFP) (2011), the American College of Cardiology (ACC) Foundation (2010), and the American Heart Association (AHA) (2010) advise against electrography in asymptomatic, low-risk individuals. • There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low-risk for coronary heart disease improves health outcomes. • False-positive tests are likely to lead to harm through unnecessary invasive procedures, over- treatment, and misdiagnosis. • Potential harms of this routine annual screening exceed the potential benefits. The AHA compiled data, including information from the Framingham Heart Study, to determine appropriate use of cardiac screening tests by looking at prognostic considerations. Those risk factors include gender and age (males over the age of 45 years) with one or more risk factors. The greater the number of risk factors a patient has, the more likely it is that the patient will benefit from screening. If a Payment Policy | EKG Services during Preventive Visit

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM patient’s risk is less than 10 percent (calculated using a risk assessment tool), screening is not recommended. The USPSTF reviewed new evidence regarding the reduction of risk for coronary heart disease (CHD) events in asymptomatic adults by screening with electrocardiography (EKG) compared with not screening and issued the following recommendations: The USPSTF recommends against screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at low risk for CHD events (D recommendation). (1) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. CODING If the code below is filed with a line level diagnosis of Z00.00 or Z00.01 on a claim with a preventive Evaluation and Management (E/M) code, the ECG code will not be separately reimbursed.
93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report RELATED POLICIES None PUBLISHED Provider Update, May 2023 Provider Update, December 2022 Provider Update, January 2020 Provider Update, December 2017 REFERENCES:

1. Moyer VA, U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:512-518. Available at http://annals.org/article.aspx?articleid=1363528(annals.org). Accessed November 21, 2012.
2. 2012 AAFP recommendations for preventive services guideline; http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08- 2005.Par.0001.File.tmp/October2012SCPS.pdf
3. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary. J Am Coll Cardiol. 2010; 56:2182-2199.
4. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. i

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS