92971
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.73
Facility
$87.51
Non-Facility
$87.51
Documentation Required
- Clinical documentation confirming diagnosis of disabling angina with NYHA Class III/IV, CCS classification, or equivalent.
- Written opinion from a cardiologist or cardiothoracic surgeon stating why PTCA or CABG is not appropriate (inoperable or high operative/postoperative risk, unfavorable coronary anatomy, or comorbidities creating excessive risk).
- Procedure must be performed under the direct supervision of a physician.
- Document patient's functional status using New York Heart Association (NYHA) and/or Canadian Cardiovascular Society (CCS) classifications.
Key Coverage Criteria
- Improvement in exercise tolerance.
- Reduction in antianginal medication use;or
- A single* course of enhanced external counterpulsation (EECP) is consideredmedically necessaryfor individuals when the criteria below are met:Disabling, chronic, stable angina, (defined as Class III or Class IV Canadian Cardiovascular Society Classification [see definition section] angina or equivalent);andIndividuals refractive to optimal medical therapy and not readily amenable to surgical intervention such as percutaneous transluminal coronary angioplasty (PTCA) or cardiac bypass due toanyof [...]
- Disabling, chronic, stable angina, (defined as Class III or Class IV Canadian Cardiovascular Society Classification [see definition section] angina or equivalent);and
- Individuals refractive to optimal medical therapy and not readily amenable to surgical intervention such as percutaneous transluminal coronary angioplasty (PTCA) or cardiac bypass due toanyof the following:Condition is inoperable;orHigh risk of operative complications or postoperative failure;orCoronary anatomy is not readily amenable to such procedures;and
- Condition is inoperable;or
6 Active Policies
ANTHEM-CG-MED-86 — CG-MED-86 Enhanced External Counterpulsation in the Outpatient Setting
BCBSIL-MED202.050 — External Counterpulsation (ECP) Therapy for Severe Angina
BCBSMT-MED202.050 — External Counterpulsation (ECP) Therapy for Severe Angina
BCBSNM-MED202.050 — External Counterpulsation (ECP) Therapy for Severe Angina
BCBSOK-MED202.050 — External Counterpulsation (ECP) Therapy for Severe Angina
Related Codes
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