Clinical UM Guideline

This document addresses the performance of resting electrocardiogram (ECG, EKG) in the screening of asymptomatic adults with no known heart disease. This document does not address the use of ECG for preoperative screening.

Note: Please see the following related document for additional information:

• CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries

Not Medically Necessary:

Resting electrocardiogram testing in adults (greater than or equal to 18 years of age) is considered not medically necessary, when both of the following are present:

1. There are no known signs or symptoms of heart disease and there is no family history of sudden cardiac death; and
2. The individual is at low risk for coronary heart disease event, where low risk is defined as a 10-year risk less than 10%.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Not Medically Necessary:
When the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Resting ECG is a noninvasive test used to detect and record the hearts electrical activity, rate, and regularity of heart as well as the strength and timing of the electrical impulses passing through each part of the heart. Resting ECG screening may be used to further evaluate symptoms related to heart disease.

According to the Centers for Disease Control and Prevention coronary heart disease (CHD), also known as coronary artery disease (CAD), is the most common heart disease reported, with an associated annual mortality of over 360,900 individuals in the U.S. in 2021. Smoking, high blood pressure, and high cholesterol are key risk factors for heart disease. Other medical conditions and lifestyle choices contribute to heart disease including diabetes, obesity, poor diet, physical inactivity and alcohol abuse (CDC, 2023).

In 2010, the American College of Cardiology Foundation and the American Heart Association (ACC/AHA) guideline for assessment of cardiovascular risk in asymptomatic adults issued a category IIb recommendation, indicating a “weak benefit > risk” ratio, for use of resting ECG in cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes. (Greenland, 2010).

The American Academy of Family Physicians (AAFP) summary of recommendations for clinical preventive services recommend against use of routine resting ECG in asymptomatic adults at low risk for CHD and found insufficient evidence for adults at increased risk for CHD events (AAFP, 2014).

The U.S. Preventive Services Task Force (USPSTF) recommends against screening with resting or exercise ECG for predication of CHD events in asymptomatic adults at low risk for CHD events. Several risk calculators are available to make a reasonable determination of the 10-year likelihood of a coronary heart disease-related event; one of the best known models is from the Framingham Adult Treatment Panel III (Framingham tool located on the National Institute of Health website, see hyperlink below). Individuals with less than a 10% likelihood of a coronary event in the next 10 years are considered to be at low risk. The USPSTF has rated the current medical evidence 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. This recommendation is based on “inadequate evidence that adding ECG to conventional risk factor assessment leads to improved stratification of individuals into high, intermediate, or low-risk groups to guide risk management.” (Moyer, 2012). In 2018, the USPSTF updated the 2012 USPSTF recommendations on screening for CHD; the panel recommends against use of screening with resting or exercise ECG to prevent cardiovascular disease (CVD) events in asymptomatic adults at low risk of CVD events. “The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events.” (USPSTF, 2018)

In summary, resting electrocardiogram testing in adults with no known signs or symptoms of heart disease (including, but not limited to coronary heart disease) does not have clinical utility in revising risk or in clinical management.

Coronary heart disease (also called coronary artery disease): A disease characterized by narrowing or blockage of the blood vessels supplying blood to the heart.

Screening: Examination of a group to separate well persons from those who have an undiagnosed pathologic condition or who are at high risk.

Sudden Cardiac Death (SCD), also called sudden death: Death resulting from an abrupt loss of heart function (cardiac arrest).

Peer Reviewed Publications:

1. Chou R, Arora B, Dana T, et al. Screening asymptomatic adults with resting or exercise electrocardiography: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011; 155:375-385.
2. Moyer VA, U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012; 157:512-518.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Family Physicians. Recommendations for clinical preventive services: coronary heart disease. Leawood, KS: American Academy of Family Physicians; 2014. Available at: https://www.aafp.org/afp/2014/0115/od1.html. Accessed on July 3, 2023.
2. Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014; 129:S46-S73. Available at: https://doi.org/10.1161/01.cir.0000437741.48606.98. Accessed on July 3, 2023.
3. Greenland P, Alpert JS, Beller GA, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010; 122:2748-2764.
4. National Institute of Health (NIH). National Heart, Lung and Blood Institute. Evidence report. Managing blood cholesterol in adults. Estimate of 10-Year Risk for Coronary Heart Disease Framingham Point Scores. Available at: http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/quick-desk-reference-html/10-year-risk-framingham-table. Accessed on July 3, 2023.
5. U.S. Preventive Services Task Force (USPSTF). Screening for cardiovascular disease risk with electrocardiography US Preventive Services Task Force recommendation statement. J American Med Assoc. 2018; 319(22):2308-2314.
6. U.S. Preventive Services Task Force (USPSTF). Screening for coronary heart disease with electrocardiography clinical summary of U.S. Preventive Services Task Force recommendations. 2018. Available at: https://www.aafp.org/pubs/afp/issues/2018/0915/od1.html. Accessed July 3, 2023.

1. American Heart Association. Coronary artery disease – coronary heart disease. Updated July 31, 2015. Available at: Coronary Artery Disease - Coronary Heart Disease | American Heart Association. Accessed on July 3, 2023.
2. American Heart Association. Electrocardiogram (ECG or EKG). Last reviewed December 27, 2022. Available at: Electrocardiogram (ECG or EKG) | American Heart Association. Accessed on July 3, 2023.
3. Centers for Disease Control and Prevention. Heart disease facts. Last reviewed May 15, 2023. Available at: https://www.cdc.gov/heartdisease/facts.htm. Accessed on July 3, 2023.
4. National Institutes of Health (NIH). National Heart, Lung, and Blood Institute. Electrocardiogram. Updated March 24, 2022. Available at: https://www.nhlbi.nih.gov/health/health-topics/topics/ekg/. Accessed on July 3, 2023.
5. National Institutes of Health (NIH). National Heart, Lung, and Blood Institute. Coronary artery disease: Diagnosis Updated March 24, 2022. Available at https://www.nhlbi.nih.gov/health/coronary-heart-disease/diagnosis. Accessed on July 3, 2023.

Resting Electrocardiogram (ECG)

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Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.

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