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Medical Policy

Policy Num:      02.002.007
Policy Name:    Routine EKG Prior To IV Sedation & other Indications
Policy ID:          [02.002.007]  [Ar / L / M+ / P-]  [0.00.00]

Last Review:      June 22, 2023
Next Review:      Policy Archived
 

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Related Policies: None

Routine EKG Prior To IV Sedation & Other Indications

Summary

A routine EKG is defined as one that is performed without there being documentation in the medical record of medical necessity.

Medical Necessity:

Those services that a doctor, exercising his prudent clinical judgment, provides to his  patients. These services must be based on the standards accepted in the medical practice and must be the product of scientific evidence published by peers,

recommendations from the different recognized specialties.  Must be appropriate and effective services that are not provided primarily for the convenience of the patient or provider and not more expensive than an alternate service similar or equivalent.

Sedation:

Drug-induced state of consciousness where the patient responds normally to intentional verbal commands, and where cognitive function and coordination may be impaired. Cardiovascular and ventilatory functions they are not affected.

Analgesia:

The use of medicines usually derived from opium, to reduce feeling of pain and/or nociceptive stimu (pain receptors in the skin).

Monitoring:

Monitoring is the continuous evaluation of the patient, before, during and after theadministration of sedatives and/or analgesics used in preparation for the endoscopic procedure

Objective

Review of the indications and benfits of an EKG exam.

Policy Statements

 Triple-S considers for payment an EKG (code 93000) prior to a ambulatory procedure and under intravenous sedation, only in high-risk patient’s risk, example:

A. Severe cardiovascular problems:

1) angina pectoris

2) history of arrhythmias

3) cardiac dysfunction

4) myocarditis

5) patients with permanent pacemakers or implanted defibrillators

B. Conditions Associated With, or Increased Risk of Disease cardiovascular:

1) advanced age > 45 years of age

2) diabetes

3) hyperlipidemia

4) smoking

5) lung diseases

6) peripheral vascular diseases

7) hypo and/or hyperthyroidism

8) collagen diseases

9) muscular dystrophies

10) liver or kidney failure

11) electrolyte disorders

12) morbid obesity (double or increase of 100lbs. of the ideal weight)

C. Use of drugs that carry the potential for cardiac toxicity:

1) antineoplastic drugs

a) doxorubicin

b) Epirubicin

c) Daunorubicin

d) Idarubicin

e) Pyrubicin

2) lithium

3) phenothiazides

4) tricyclic antidepressants

5) erythromycin

D. Neurological disorders

1. Autonomic Neuropathies

2. Documentation:

The justification for performing the EKG must be duly documented in the patient file. If it is not included, it will be considered as absence of medical necessity and payment will not be considered.

Policy Guidelines

EKG services are covered diagnostic tests when there are documented signs and symptoms or other clinical indications for providing the service.  MEKG services should not routinely be performed as part of a preventive exam unless the patient has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test.  

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. 

Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Guidelines from the U.S. Preventive Services Task Force (USPSTF) (2011), the American Academy of Family Physicians (AAFP) (2011), the American College of Cardiology (ACC) Foundation (2010), and the American Heart Association (AHA) (2010) advise against electrography in asymptomatic, low-risk individuals.

 There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low-risk for coronary heart disease improves health outcomes.

The results of the ECG must be relevant to the management of the patient.  False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis.

 Potential harms of this routine annual screening exceed the potential benefit.

The AHA compiled data, including information from the Framingham Heart Study, to determine appropriate use of cardiac screening tests by looking at prognostic considerations. Those risk factors include gender and age (males over the age of 45 years) with one or more risk factors. The greater the number of risk factors a patient has, the more likely it is that the patient will benefit from screening. If a patient’s risk is less than 10 percent (calculated using a risk assessment tool(hp2010.nhlbihin.net)), screening is not recommended.

The USPSTF reviewed new evidence regarding the reduction of risk for coronary heart disease (CHD) events in asymptomatic adults by screening with electrocardiography (EKG) compared with not screening and issued the following recommendations: The USPSTF recommends against screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at low risk for CHD events (D recommendation). (1) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events

Regulatory Status

N/A

Rationale

Population Reference No. 1

An ECG is not a covered benefit when used for screening purposes or as part of a routine physical examination. Routine physical examinations (screening) are evaluation and management services supplied in the absence of associated signs, symptoms or complaints. 

EKG services should not routinely be performed as part of a preventive exam unless the patient has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test.

Population Reference No. 2

The results of the ECG must be relevant to the management of the patient. The patient has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.van Klei WA, Bryson GL, Yang H, et al. The value of routine preoperative electrocardiography in predicting myocardial infarction after noncardiac surgery. Ann Surg. 2007;246:165–170. [PMC free article] [PubMed

2.Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576–3581. [PubMed]

Codes

Appplicable Modifiers

N/A

Policy History