Enhanced External Counterpulsation - MCS a

Clinical Medical Policy Department 

Clinical Affairs Division 

Enhanced External Counterpulsation (EECP) 

[For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr go to “Comunicados a Proveedores”, 

and click “Cartas Circulares”.] 

Medical Policy: 

MP-ME-01-04 

Original Effective Date: January 17, 2005 

Revised: October 22, 2014 

Next Revision: August, 2015 

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, 

Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions 

apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral 

authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the 

aforementioned exceptions. 

DESCRIPTION 

Enhanced External Counter Pulsation (EECP) is a non-invasive technique that provides augmentation of 

diastolic blood flow, using three air cuffs, which inflates and deflates in synchronization with the patient 

cardiac cycle. These cuffs are positioned in the legs: 

One at the calf level 

The second slightly above the knee; and 

The third one on the thigh 

The cuffs are connected to an ECG. At the time that the heart is in diastole, (time of relaxation) the cuffs 

are inflated sequentially (distal to proximal) compressing the blood vessels in the lower limb. This action 

results in: 

The increase in diastolic pressure 

Generation of retrograde arterial blood flow; and 

An increase in venous return and consequently, cardiac output 

It is thought that the pressure created recruits and enlarges collateral vessels. In summary, this 

technique delivers more oxygen to the ischemic myocardium by increasing coronary blood flow during 

diastole, while at the same time decrease the demand for oxygen by diminishing the work requirements 

of the heart. EECP technique is recommended for patients with severe chronic stable angina and do not 

qualify for invasive procedures. The recommended treatment is a full course of EECP usually consisting 

of thirty-five (35) one-hour sessions, offered once or twice daily, and covers a period of four to seven (7) 

weeks. 

COVERAGE 

Benefits may vary between groups and contracts. Please refer to the appropriate member certificate 

and subscriber agreement contract for applicable diagnostic imaging, laboratory, machine tests, 

benefits and coverage. 

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 

Medical technology is constantly changing and we reserves the right to review and update our policies periodically. 

Medical Card System, Inc. 

All Rights Reserved® 

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INDICATIONS 

Medical Card System, Inc., (MCS) will consider Enhanced External Counterpulsation (EECP) medically 

necessary for patients with disabling angina that meet all of the following criteria: 

1. Patients who have been diagnosed with disabling angina (Class III or Class IV, New York Heart 

Association Functional Classification or equivalent classification-see appendix) who in the 

opinion of a cardiologist or cardiothoracic surgeon, are NOT readily amenable to surgical 

intervention such as Percutaneous Transluminal Coronary Angioplasty (PTCA) or cardiac bypass, 

because: 

a. Their condition is inoperable, or at high risk of operative complications or postoperative 

failure; 

b. Their coronary anatomy is not readily amenable to such procedures; or 

c. They have co-morbid states that create excessive risk 

2. Coverage beyond a full course of thirty-five (35) one-hour sessions should be rare. Patients are 

re-evaluated and if there is no angina class improvement after an initial thirty-five (35) hours of 

treatment, up to ten additional hours of treatment may be covered up until they improve by at 

least one angina class. 

3. Re-treatment may be considered medically necessary by MCS after one year of completion of 

the initial full course of thirty five (35) hours of EECP, and the patient meets initial criteria and 

medical necessity for EECP. 

CONTRAINDICATIONS 

1. Cardiac catheterization within 2 weeks (may cause bleeding at the femoral puncture site); or 

2. Arrhythmias such as atrial fibrillation, atrial flutter, ventricular tachycardia, and frequent 

premature ventricular beats (might interfere with the device’s triggering mechanism); 

3. Severe peripheral vascular disease and/or phlebitis (increased risk of thromboembolus); or 

4. Deep vein thrombosis, and stasis ulcers; or 

5. Bleeding diatheses, Coumadin (warfarin) therapy with PT greater than 15 seconds and/or INR 

greater than 2.0 (cuffs could cause bleeding in legs); or 

6. Pregnant women and women of childbearing potential who do not employ a reliable 

contraceptive method (possible danger to the fetus). 

7. Significant aortic insufficiency where regurgitation would prevent diastolic augmentation 





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PRECAUTIONS 

LIMITATIONS 

1. Severe hypertension, greater than 180/110 mmHg, (treatment could produce diastolic blood 

pressure above acceptable limits). 

2. Heart rate more than 120 bpm should be controlled prior to treatment with enhanced 

external counterpulsation. 

3. Patients at high risk of complications from increased venous return should be carefully 

chosen and monitored during treatment with enhanced external counterpulsation. 

Decreasing cardiac afterload by optimizing cuff inflation and deflation timing may help 

minimize increased cardiac filling pressures and the possibility of pulmonary congestion due 

to increased venous return. 

4. Patients with clinically significant valvular disease should be carefully chosen and monitored 

during treatment with enhanced external counterpulsation. Certain valve conditions, such 

as significant aortic insufficiency or severe mitral or aortic stenosis, may prevent the patient 

from obtaining benefit from diastolic augmentation and reduced cardiac afterload in the 

presence of increased venous return. 

1. EECP is considered investigational for any condition not listed above, including, but not 

limited to congestive heart failure, acute myocardial infarction and cardiogenic shock 

because there is inadequate scientific evidence to permit conclusions about the efficacy of 

this treatment for conditions other than disabling angina as specified in the covered services 

section above. 

2. Patient could be re-evaluated and if there is not angina class improvement after the initial 

thirty five (35) hours of treatment, a limit of ten additional hours of treatment may be 

covered until they improve by at least one angina class. . 

3. Procedure must be performed under direct supervision of a physician. The physician must 

be present in the office suite and immediately available to provide assistance and direction 

throughout the time the personnel is performing the service. 

4. The use of hydraulic versions of these treatment devices is NON-COVERED, and therefore 

will be denied. 





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CODING INFORMATION 

HCPCS® CODES (LIST MAY NOT BE ALL INCLUSIVE) 

HCPCS CODES 

G0166 

DESCRIPTION 

External Counterpulsation, Per Treatment Session 

2014 HCPCS LEVEL II Professional Edition® (American Medical Association). 

ICD-9 CM® DIAGNOSIS CODES (LIST MAY NOT BE ALL INCLUSIVE) 

ICD-9 CM® 

DESCRIPTION 

CODES 

413.9 Other and unspecified angina pectoris 

2014 ICD-9-CM® For Physicians, VOLUMES I & II, Professional Edition (American Medical Association). 

ICD-10 Codes (Preview Draft) 

In preparation for changes in the coding systems form ICD- 9 to ICD -10, this policy includes a sample list 

of ICD-10 codes for your reference. These codes may become subject to changes or modifications since 

they will be in effect on October 1, 2015. 

ICD 10 CODES 

I20.8 Other forms of angina pectoris 

I20.9 Angina pectoris, unspecified 

DESCRIPTION 

REFERENCES 

1. Aarush Manchanda, MD, and Ozlem Soran, MD, MPH, FACC, FESC. (2007). Enhanced External 

Counterpulsation and Future Directions Step Beyond Medical Management for Patients with 

Angina and Heart Failure. J Am Coll Cardiol. 50 (16), 1523-1531. Accessed on August 20, 2014. 

Available at URL address: http://content.onlinejacc.org/article.aspxarticleid=1138569 

2. Centers for Medicare & Medicaid Services (CMS), First Coast Service Options, Inc. LCD for 

External Counterpulsation (ECP) (L29322). For services performed on or after 3/2/2009. 

Accessed on August 20, 2014. Available at URL address: http://www.cms.gov/medicarecoverage-database/details/lcddetails.aspxLCDId=29322&ContrId=371&ver=4&ContrVer=1&CntrctrSelected=198*1&Cntrctr=1 

98&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+- 

+Part+B)&s=46&bc=AggAAAIACAAAAA%3d%3d& 

3. Center for Medicare & Medicaid Services (CMS). External counterpulsation therapy. Medicare 

Coverage Issues Manual Section 35-74, Issue #CAG-00003. Accessed on August 20, 2014. 

Available at URL address: http://www.dmerc.com/manual/medical%20procedures.htm#_1_80 





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4. Centers for Medicare & Medicaid (CMS), National Coverage Determinations, Manual System 

Chapter 1. Rev. 171, 07-18-14. Section 20.20. Accessed on August 20, 2014. Available at URL 

address: https://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf 

5. Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual. 

Transmittal 898. Pub. 100-04. External Counterpulsation Therapy (ECP). Date: March 31, 2006. 

Accessed on August 20, 2014. Available at URL address: http://www.cms.gov/Regulations-and- 

Guidance/Guidance/Transmittals/downloads/R898CP.pdf 

6. Goldman, L., Hashimoto, B., Cook, E.F., (1981). Comparative reproducibility and validity of 

systems for assessing cardiovascular functional class: Advantages of a new specific activity scale. 

Circulation, 64 (6). 1227-1264. Accessed on August 20, 2014. Available at URL address: 

http://circ.ahajournals.org/content/64/6/1227.long 

7. Sayami, L.A., Ullah, M., Rahman M.T., Rahman, Z., Roy, D., Majumder, A.AS. (2010). Enhanced 

External Counterpulsation A Review. Cardiovascular. J. 2 (2): 236-244. Searched on August 20, 

2014. Accessed on August 20, 2014. Available at URL: 

http://www.banglajol.info/bd/index.php/CARDIO/article/viewFile/6647/5111 

8. Sinvhal, R. M., Gowda R. M., Khan, I. A., (2003). Enhanced external counterpulsation for 

refractory angina pectoris. Heart, (89), 830–833. Accessed on August 21, 2014. Available at URL 

Address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767754/pdf/hrt08900830.pdf 

9. Vasomedical Inc. (2004). The Physician’s Guide to EECP therapy. Accessed on August 20, 2014. 

Available at URL address: http://lifelineheart.com/PDF/EECP%20Presentation.pdf 

POLICY HISTORY 

DATE ACTION COMMENT 

January 17, 2005 

Origination of Policy 

December 18, 2007 Revised Added (Delivery of sessions within four to seven weeks for a total of 35 

hours of treatment versus 5 weeks.) 

August 11, 2009 Revised Policy revised to add a new coverage: retreatment of EECP after one year 

of completion of the initial full course of 35 hours of EECP. 

HCPC code (G0166) and ICD-9 Codes (413.0, 413.1, and 413.9) added to 

the policy. Contraindication #3 of policy MP-ME-01-04 of 2008 (Aortic 

insufficiency (regurgitation might prevent diastolic augmentation) was 

deleted from 2009 policy. Contraindication #4 of policy MP-ME-01-04 of 

2008 policy the word “Severe” was added to peripheral 

vascular disease to read, Severe vascular disease and/or phlebitis 

(increased risk of thromboembolus) for 2009 policy. Contraindication #5 

of policy MP-ME-01-04 of 2008 the word “varicosities” was deleted to 

read, Deep vein thrombosis and stasis ulcers for 2009 policy. 

August 24, 2010 Revised Deleted ICD-9 Codes 413.0, 413.1 

The following limitations were added to the policy: 

1. Coverage beyond a full course of thirty-five (35) one-hour sessions 

should be rare. Members are re-evaluated and if there is no angina 

class improvement after an initial thirty-five (35) hours of treatment, 

up to ten additional hours of treatment may be covered up until they 

improve by a least one angina class. 





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2. Procedure must be performed under direct supervision of a physician. 

The physician must be present in the office suite and immediately 

available to provide assistance and direction throughout the time the 

personnel is performing the service. 

3. The use of hydraulic versions of these treatment devices is NON- 

COVERED, and therefore will be denied 

August 25, 2011 Revised Added Precautions 

August 10, 2012 Yearly Review References updated. 

December 10, 2012 Reviewed Policy was reviewed and approved by the Medical Card System (MCS) 

Medical Advisory Committee (MAC) on December 10, 2012. 

August 20, 2013 Yearly Review 1. References updated – (#1, #6 and #7 were added to the Medical 

Policy). 

2. Contraindication #7 was added to the Medical Policy. 

3. Precautions #3 and #4 were added to the Medical Policy. 

February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was 

added to the policy. 

August 21, 2014 Yearly Review 1. References updated. 

2. To the Limitations section: 

‣ Limitations #2 was eliminated and was maintained in the 

Indications section according to the LCD (L29322). 

3. Reference #8 was added to Policy. 

Appendix 

New York Heart Association Functional Classification of Cardiac Disability 

Class I: Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity 

does not cause undue fatigue, palpitation, dyspnea, or anginal pain. 

Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. 

Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. 

Class III: Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at 

rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. 

Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. 

Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is 

undertaken, discomfort is increased. 

Source: Adapted from Goldman et al (1981) 

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of 

benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with 

the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are 

developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but 

not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical 

practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical 

Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS) 

medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as 

deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, 

quality, and levels of care and treatment they choose to provide. 





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Enhanced External Counterpulsation - MCS a

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