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Date Printed: June 26, 2017: 01:24 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-93000-22

Original Effective Date: 11/15/00

Reviewed: 05/28/08

Revised: 05/11/14

Subject: Signal Averaged Electrocardiography (SAECG)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Signal-averaged electrocardiography (SAECG) is a technique involving computerized analysis of small segments of a standard EKG to detect abnormalities, termed ventricular late potentials (VLP), that would be otherwise obscured by “background” skeletal muscle activity. VLPs reflect aberrant, asynchronous electrical impulses arising from viable isolated cardiac muscle bordering an infarcted area and are thought to be responsible for ventricular 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 being at high risk of ventricular arrhythmias and thus sudden death may be treated with drugs to suppress the emergence of arrhythmias or automatic implantable cardiac defibrillators (AICD) to promptly detect and terminate tachyarrhythmias when they occur. Since sudden cardiac death, whether from arrhythmias or pump failure, is one of the most common causes of death after a previous myocardial infarction, 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, arrhythmias detected on Holter monitor or electrophysiologic studies, heart rate variability, and baroreceptor sensitivity. T-wave alternans is another technique for risk stratification. T-wave alternans measures beat-to-beat variability, while SAECG measures beat-averaged conduction.

POSITION STATEMENT:

SAECG is considered experimental or investigational, as there is insufficient clinical evidence to support the use of SAECG for ALL applications, and specifically for the following indications:

There is inadequate scientific data to evaluate the impact on patient management and net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

93278

Signal-averaged electrocardiography (SAECG), with or without ECG (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Electrocardiographic Services (20.15) located at cms.gov.

DEFINITIONS:

Ventricular tachycardia: greater than 100 beats/minute arising from a ventricular focus; usually between 150-200 beats/minute.

Cardiomyopathy: any disease affecting the heart muscle, diminishing cardiac performance.

Monomorphic: form unchanged.

RELATED GUIDELINES:

T-Wave Alternans, 01-93000-23

OTHER:

Other names used to report signal-averaged electrocardiography:

Computer Analysis of Electrocardiography
Electrocardiography, Signal-Averaged
SAECG
Signal-Averaged Electrocardiography

REFERENCES:

  1. ACC/AHA/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Accessed at acc.org on 05/01/09.
  2. Agency for Health Care Policy & Research (AHCPR). U.S. Department of Health and Human Services. Health Technology Assessment Number 11. (1998). “Signal-Averaged Electrocardiography” (AHCPR Pub No 98-0020).
  3. American College of Cardiology. Signal-averaged electrocardiography. Expert Consensus Document. J. Am. Coll. Cardiol. 1996 Jan; 27(1): 238-249.
  4. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Ornato JP. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4; 44(3): E1-E211.
  5. Bailey JJ, Berson AS, Handelsman H, Hodges M. Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction. J Am Coll Cardiol. 2001 Dec; 38(7): 1902-11.
  6. Blue Cross Blue Shield Association Medical Policy Reference Manual – 2.02.04 Signal Averaged Electrocardiography, 08/07.
  7. Blue Cross Blue Shield Association Technology Evaluation Center “Signal-Averaged Electrocardiography for Risk Stratification Following Acute Myocardial Infarction” (01/96).
  8. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 20.15 Electrocardiographic (EKG) Services (12/04).
  9. David S. Cannom, MD; Eric N. Prystowsky, MD. Management of Ventricular Arrhythmias: Detection, Drugs, and Devices. JAMA. 1999; 281:172-179.
  10. Goldberger JJ, Cain ME, Hohnloser SH, et al, American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death, J Am Coll Cardiol 2008; 52:1179-99.
  11. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235.
  12. Taber's Cyclopedic Medical Dictionary, 1999, F.A. Davis Co., Phil., PA.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/09.

GUIDELINE UPDATE INFORMATION:

11/15/00

Medical Coverage Guideline Developed.

02/15/02

Medical Coverage Guideline Reformatted.

03/15/03

Reviewed; no changes.

09/15/06

Scheduled review and revision of guideline consisting of updated references and addition of rationale for investigational statement.

07/15/07

Annual review, investigational status maintained, reformatted guideline, references updated.

09/15/08

Scheduled review; no change in position statement; references updated.

06/15/09

Annual review: position statement maintained; references updated.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: June 26, 2017: 01:24 AM