Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-25
Topic:	Displacement Cardiokymography (CKG) - NCD 20.24
Effective Date:	June 15, 2009
Issued Date:	April 5, 2010

General Policy

Cardiokymography (CKG) is a noninvasive procedure used to detect stress induced abnormalities in the left wall of the heart. This procedure provides an additional means for the diagnosis and assessment of coronary artery disease. Although CKG may be performed as an independent test, the greatest benefit of this test is achieved through its adjunctive use with electrocardiographic (ECG) stress testing.

Indications and Limitations of Coverage

CKG testing is considered a covered service only when used as an adjunct to ECG stress testing in evaluating coronary artery disease and only when the following clinical indications are present:

For male patients, atypical angina pectoris or nonischemic chest pain ; or,
For female patients, angina, either typical or atypical must be reported.

Payment for cardiokymography will be denied as not medically necessary when reported with a condition not included on this policy. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Q0035

CMS Online Manual Pub. 100-3, Chapter 1, Section 20.24

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

413.9

786.50

ICD-10 Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.