Cardiointegram Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|06|2010 POLICY LAST REVIEWED: 03|19|2025 OVERVIEW Cardiointegram (CIG) is a technique intended to detect abnormalities in the standard 12-lead electrocardiogram in individuals at risk of cardiac ischemia. This policy is applicable to Commercial Products only. For Medicare Advantage Plans, see Related Policies section. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Commercial Products Cardiointegram is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary benefits/coverage. BACKGROUND A cardiointegram device consists of a microcomputer that receives output from a standard electrocardiogram (EKG) and transforms it to produce a graphic representation of heart electrophysiologic signals. This procedure may be used as a substitute for exercise tolerance testing with thallium imaging in patients for whom a resting EKG may be inadequate to identify changes compatible with coronary artery disease. Cardiointegram, a technique intended to detect abnormalities in the standard 12-lead electrocardiogram that are not identifiable by competent routine interpretation in patients at risk of cardiac ischemia, is considered not medically necessary because there is insufficient evidence to support conclusions regarding its efficacy as a diagnostic tool.
CODING Commercial Products The following HCPCS code(s) is not medically necessary: S9025 Omnicardiogram/cardiointegram
RELATED POLICIES Medicare Advantage Plans National and Local Coverage Determinations PUBLISHED Provider Update, May 2025 Provider Update, April 2024 Provider Update, May 2023 Medical Coverage Policy | Cardiointegram

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

Provider Update, September 2022 Provider Update, September 2021

REFERENCES

1. Centers for Medicare & Medicaid Services (CMS). NCD for cardiointegram (CIG) as an alternative to stress test or thallium stress test. CMS Manual System. Pub. 100-3. Medicare National Coverage, Chapter 1, Part 1, Section 20.27 Baltimore, MD: CMS; last modified April 23, 2009.
2. Gould LA, Betzu R, and et al. The resting cardiointegram: Correlation with stress thallium perfusion studies. Angiology, 1988; 39(4):375-80.
3. Health Care Financing Administration (HCFA) coverage Issues Manual Diagnostic Services. Section 50-47.
4. Nay P, Kannell WB, Castelli, McNamara PM. The omnicardiogram study of a proposed method for detecting coronary heart disease in an asymptomatic population. Circulation. 1975; 51: 462-466.

5. Teichholz LE, Steinmetz MY, et al. The cardiointegram: detection of coronary artery disease in males with chest pain and a normal resting electrocardiogram. J Electrocardiol. 1986; 19(3): 257-267.

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   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