G0166, External counterpulsation, per treatment session
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$102.87
Non-Facility
$102.87
Documentation Required
- Treatment plan indicating intended number of sessions (up to 35 sessions per course) and justification when repeat treatment is requested.
- Documentation that the member has disabling chronic stable angina (New York Heart Association Class III or Class IV angina) per the Appendix (NYHA functional classification).
- Documentation that the member is refractory to maximum medical therapy.
- Documentation that the member is not readily amenable to surgical intervention such as PTCA or cardiac bypass and that at least one of the following applies: Their condition is inoperable; They are at high-risk of operative complications or post-operative failure; Their coronary anatomy is not readily amenable to such procedures; They have co-morbid states that create excessive risk.
Key Coverage Criteria
- HCPCS codes covered if selection criteria are met: G0166 External counterpulsation, per treatment session
- A course of up to 35 sessions of ECP for members who meet both of the following criteria: Members with disabling chronic stable angina (New York Heart Association Class III or Class IV angina) (see Appendix); and Members are refractory to maximum medical therapy and not readily amenable to surgical intervention such as percutaneous transluminal coronary angioplasty (PTCA) or cardiac bypass due to any of the following: Their condition is inoperable; or They are at high-risk of operative complicat [...]
- Repeat courses of ECP for persons with chronic stable angina if all of the following criteria are met: Member meets medical necessity criteria for ECP in Section I.A. above; and Prior ECP has resulted in a sustained improvement in symptoms with: A significant (greater than 25 %) reduction in frequency of anginal symptoms; or Improvement by 1 or more anginal classes; and Three or more months has elapsed from the prior ECP treatment;
- ICD-10 codes covered if selection criteria are met: I20.1 - I20.9 Angina pectoris [disabling, refractory to maximum medical therapy and not readily amenable to surgical intervention]
- ICD-10 codes covered if selection criteria are met: I25.111 - I25.119 Atherosclerotic heart disease of native coronary artery with angina pectoris
- ICD-10 codes covered if selection criteria are met: I25.701 - I25.709 Atherosclerosis of coronary artery bypass graft(s) with angina pectoris
9 Active Policies
ANTHEM-CG-MED-86, CG-MED-86 Enhanced External Counterpulsation in the Outpatient Setting
AETNA-CPB-0262, External Counterpulsation (ECP)
MED202.050, External Counterpulsation (ECP) Therapy for Severe Angina
BCBSIL-MED202.050, External Counterpulsation (ECP) Therapy for Severe Angina
BCBSMT-MED202.050, External Counterpulsation (ECP) Therapy for Severe Angina
Related Codes
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