Enhanced External Counterpulsation (EECP)
DESCRIPTION
Enhanced external counterpulsation (EECP) is a noninvasive treatment that uses timed, sequential inflation of pressure cuffs on the calves, thighs and buttocks to augment diastolic pressure, decrease left ventricular afterload, and increase venous return. Augmenting diastolic pressure displaces a volume of blood backwards into the coronary arteries during diastole when the heart is in a state of relaxation and the resistance in the coronary arteries is at a minimum. The resulting increase in coronary artery perfusion pressure may enhance coronary collateral development or increase flow through existing collaterals. In addition, when the left ventricle contracts, it faces a reduced aortic pressure since the counterpulsation has somewhat emptied the aorta. EECP has been primarily investigated as a treatment for chronic stable angina.
Intra-aortic balloon counterpulsation is a more familiar, invasive form of counterpulsation that is used as a method of temporary circulatory assistance for the ischemic heart, often after an acute myocardial infarction. In contrast, EECP is thought to provide a permanent effect on the heart by enhancing the coronary collateral development. A course of EECP treatment typically includes 35 hours performed in 1- to 2-hour sessions in the physician's office. The multiple components of the procedure include the use of the device itself, finger plethysmography to follow the blood flow, continuous EKGs to trigger inflation and deflation, and optional use of pulse oximetry to measure oxygen saturation before and after treatment.
POLICY
Enhanced external counterpulsation for the treatment of conditions/diseases, including, but not limited to, the following: chronic stable angina, acute myocardial infarction, cardiogenic shock, erectile dysfunction and ischemic stroke is considered investigational.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
There is insufficient evidence to draw conclusions about the benefits of EECP. The available evidence is limited by lack of comparison groups in more reported studies.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2008). Enhanced external counterpulsation (EECP) for chronic stable angina or congestive heart failure. (2.02.06). Retrieved March 8, 2010 from BlueWeb. (21 articles and/or guidelines reviewed)
Casey, D. P., Conti, C. R., Nichols, W. W., Choi, C. Y., Khuddus, M. A., & Braith, R. W. (2008). Effect of enhanced external counterpulsation on inflammatory cytokines and adhesion molecules in patients with angina pectoris and angiographic coronary artery disease. American Journal of Cardiology, 101 (3), 300-302. (Level 2 - Industry sponsored)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, November). External counterpulsation (ECP) for severe angina - covered (NCD 20.20, p.2-2, 2-25).The Ingenix Complete Guide to Medicare Coverage Issues.
Erdling, A., Dondesson, S., Petterson, T. & Edvinsson, L. (2008). Enhanced external counter pulsation in treatment of refractory angina pectoris: two year outcome and baseline factors associated with treatment failure. BMC Cardiovascular Disorders, 8 (39). (Level 4 Evidence - Independent study)
Han, J.H, Leung, T.W., Lam, W.W., Soo, Y.O., Alexandrov, A.W., Mok, V., et al. (2008). Preliminary findings of external counterpulsation for ischemic stroke patient with large artery occlusive disease. Stroke, Journal of the American Heart Association. 39 (4), 1340-1343. (Level 2 Evidence - Independent study)
Hayes. Medical Technology Directory. (2008, June). External Counterpulsation. Retrieved March 8, 2010 from www.Hayesinc.com/subscribers. (36 articles and/or guidelines reviewed)
Manchanda, A., & Soran, O. (2007). Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. Journal of the American College of Cardiology, 50 (16), 1523-1531.
McKenna, C., McDaid, C., Suekarran, S., Hawkins, N., Claxton, K., Light, k. et al. Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systemic review and economic analysis. Health Technol Assess 2009; 13(24).
National Guideline Clearinghouse. (2007, August). ACC/AHA 2007 guideline update for the management of patients with unstable angina/non ST-elevation myocardial infarction. Retrieved March 8, 2010 from http://www.guidelines.gov.
Soran, O., Kennard, E. D., Kfoury, A., G., & Kelsey, S. F. (2006). Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction. American Journal of Cardiology, 97 (1), 17-20. (Level 2 Evidence - Industry sponsored)
Urano, H., Ikeda, H., Ueno, T., Matsumoto, T., Murohara, T., Imaizumi, T. (2001). Enhanced external counterpulsation improves exercise tolerance, reduces exercise-induced myocardial ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. Journal of the American College of Cardiology, 37 (1), 93-99.
ORIGINAL EFFECTIVE DATE: 9/13/1999
MOST RECENT REVIEW DATE: 4/22/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.