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Signal-averaged electrocardiography (ECG) (SAECG) is primarily intended to identify persons at risk for future episodes of ventricular tachycardia, ventricular fibrillation or sudden cardiac death. ECG signals are amplified, filtered and averaged with computer-assistance. The goal is to detect "late potentials," low amplitude signals that are thought to represent areas of slow conduction within the ventricular myocardium that cannot be detected with standard ECG equipment. In addition to identifying high risk patients, SAECG has been proposed as a way of predicting response to programmed intracardiac electrical stimulation.
POLICYSignal-averaged electrocardiography (SAECG) is considered investigational in all applications.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY5/1992: Issued
4/4/2001:Policy reviewed; Managed Care Requirements deleted, Code Reference updated
5/2001: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
6/7/2002: Code Reference section updated, ICD-9 procedure code 89.59 added
8/7/2003: Policy reviewed, no changes
8/15/2005: Code Reference section reviewed, no changes
5/14/2009: Policy reviewed, no changes
02/23/2011: Policy reviewed; no changes
01/18/2012: Policy reviewed; policy statement unchanged. Deleted outdated references from sources section.
08/14/2015: Medical policy revised to add ICD-10 codes.
06/08/2016: Policy number L.2.02.403 added. Investigative definition updated in Policy Guidelines section.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.02.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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