Signal-Averaged Electrocardiography (SAECG) Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|02|2001 POLICY LAST REVIEWED: 02|04|2026 OVERVIEW Signal-averaged electrocardiography (SAECG) is a technique involving computerized analysis of small segments of a standard ECG to detect abnormalities, termed ventricular late potentials (VLPs), that would be otherwise obscured by “background” skeletal muscle activity.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Signal-averaged electrocardiography is not covered as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome, including, but not limited to, its use:  as a technique of risk stratification for arrhythmias after prior myocardial infarction;  in patients with cardiomyopathy;  in patients with syncope;  as an assessment of success after surgery for arrhythmia;  in the detection of acute rejection of heart transplants;  as an assessment of efficacy of antiarrhythmic drug therapy; or  in the assessment of success of pharmacological, mechanical, or surgical interventions to restore coronary artery blood flow. Commercial Products Signal-averaged electrocardiography is not medically necessary as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome, including, but not limited to, its use:  as a technique of risk stratification for arrhythmias after prior myocardial infarction;  in patients with cardiomyopathy;  in patients with syncope;  as an assessment of success after surgery for arrhythmia;  in the detection of acute rejection of heart transplants;  as an assessment of efficacy of antiarrhythmic drug therapy; or  in the assessment of success of pharmacological, mechanical, or surgical interventions to restore coronary artery blood flow. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage, Subscriber Agreement or Benefit Booklet for not medically necessary coverage/benefits. BACKGROUND Ventricular late potentials (VLPs) reflect aberrant, asynchronous electrical impulses arising from viable isolated cardiac muscle bordering an infarcted area and are thought to be responsible for ventricular Medical Coverage Policy | Signal-Averaged Electrocardiography (SAECG)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

tachyarrhythmias. Therefore, VLPs, as measured by SAECG, have been investigated as a risk factor for arrhythmic events in patients with a variety of cardiac conditions, including cardiomyopathy and prior history of myocardial infarction (MI). Patients considered at high risk of ventricular arrhythmias and thus sudden death may be treated with drugs to suppress the emergence of arrhythmias or with implantable cardiac defibrillators (ICDs) to promptly detect and terminate tachyarrhythmias when they occur. Because sudden cardiac death, whether from arrhythmias or pump failure, is one of the most common causes of death after a previous MI, there is intense interest in risk stratification to target therapy. Patient groups are divided into those who have not experienced a life-threatening arrhythmia (i.e., primary prevention) and those who have (i.e., secondary prevention). SAECG is just one of many risk factors that have been investigated. Others include left ventricular ejection fraction (LVEF), arrhythmias detected on Holter monitor or electrophysiologic studies, heart rate variability, and baroreceptor sensitivity. T-wave alternans is another technique for risk stratification; it measures beat-to-beat variability, while SAECG measures beat-averaged conduction.

SAECG has not demonstrated improvements in health outcomes and remains not medically necessary for all indications.

CODING Medicare Advantage Plans and Commercial Products The following code is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: 93278 Signal-averaged electrocardiography (SAECG), with or without ECG

RELATED POLICIES None

PUBLISHED Provider Update, April 2026 Provider Update, March 2025 Provider Update, April 2024 Provider Update, April 2023 Provider Update, July 2022

REFERENCES

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

American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). J Am Coll Cardiol 2002; 40(9):1703-19.

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