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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.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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 Deleted outdated references from sources section.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.
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.