|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
ECP may be considered medically necessary when BOTH of the following are met:
Although these and similar devices are cleared by the Food and Drug Administration (FDA) for use in treating a variety of conditions, including stable or unstable angina pectoris, acute myocardial infarction, and cardiogenic shock, coverage is limited to its use in patients with stable angina pectoris, since only that use has developed sufficient evidence to demonstrate its medical effectiveness.
Documentation in the medical record must contain a history and physical pertinent to the indications of this policy, and be available upon request.
Repeat courses of ECP will be considered on a case by case basis for persons with chronic stable angina if ALL of the following criteria are met:
ECP for any other indication is considered not medically necessary.
Hydraulic versions of ECP devices are non-covered due to the limited use of the device.
New York Heart Association Functional Classification of Cardiac Disability:
Source: American Heart Association, Classes of Heart Failure. 2017.
External cardiac assist (92971), ECG rhythm strip and report (93040 or 93041), and plethysmography (93922 or 93923), or other monitoring tests for examining the effects of this treatment are not separately reimbursable on the same day as ECP , unless they occur in a clinical setting not connected with the delivery of the ECP service.
A full course of therapy usually consists of up to 35 one (1) hour treatments, which may be offered once (1) or twice (2) daily, usually five (5) days per week.
This procedure must be done under direct supervision of a physician.
External Counterpulsation (ECP) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider cannot bill the member for the non-covered service.
08/2016 Revised Criteria for External Counterpulsation
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.