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

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

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%.

This document describes clinical studies and expert recommendations, and explains when resting electrocardiogram screening in adults is not clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Resting electrocardiogram, also called ECG or EKG, is a test that checks the heart’s electrical activity while a person is resting. It can show the heart rate and rhythm. It can also show the timing and strength of electrical signals in the heart and may help check symptoms that could be linked to heart disease. It may be used in adults who do not have signs or symptoms of heart disease and have no known heart disease, those who do, and also for individuals who are getting ready for surgery. For adults at low risk for heart disease who do not have symptoms, routine screening is not recommended. In this group, the test has not been shown to help predict heart problems in a way that improves care. It may also lead to follow-up testing or other care that is not needed and may cause harm.

What the Studies Show

Studies reviewed by expert groups found that routine ECG screening does not add enough useful information for adults who have no symptoms and are at low risk for heart disease. The test may find changes that do not lead to better care.

Resting ECG is painless and does not involve surgery. Still, the results can lead to harm. A result may suggest a heart problem when there is not one. This can lead to more tests or treatment that may not help. Unnecessary or unproven tests can lead to needless worry, or to treatment that does not help.

When is this not Clinically Appropriate?

Resting ECG screening is not clinically appropriate for adults when all of the following are true:

• The adult is 18 years or older; and
• The adult has no known signs or symptoms of heart disease; and
• The adult does not have a family history of sudden cardiac death; and
• The adult is at low risk for a coronary heart disease event. Low risk means the chance of this type of heart event is less than 10% over the next 10 years.

This test is not clinically appropriate in the situation above because studies have not shown that it improves health for adults at low risk who do not have symptoms. The U.S. Preventive Services Task Force (USPSTF) recommends against ECG screening for these adults. Other expert groups also recommend against routine ECG screening in low-risk adults without symptoms. They found that the test does not help enough with risk prediction or care decisions.

Return to Description

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.

Summary

Resting ECG is a noninvasive test used to detect and record the heart’s electrical activity, rate, and regularity 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. The use of resting ECG testing in asymptomatic adults is not recommended in the most recent statements by the American College of Cardiology (ACC), the American Heart Association (AHA), the American Academy of Family Physicians (AAFP), and the U.S. Preventive Services Task Force (USPSTF). Thus, such testing is considered not medically necessary in adults with no known signs or symptoms of heart disease (including, but not limited to coronary heart disease) because it does not have clinical utility in revising risk or in clinical management.

Discussion

According to the Centers for Disease Control and Prevention (CDC) 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 375,000 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, 2024).

In 2010, the 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 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 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 (USPSTF, 2018).

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 people 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 August 13. 2026.
2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019; 74(10):e177-e232.
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. November 2013. Available at: http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/quick-desk-reference-html/10-year-risk-framingham-table. Accessed on August 13, 2026.
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.

1. American Heart Association. Coronary artery disease - coronary heart disease. Updated January 10, 2024. Available at: https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/coronary-artery-disease. Accessed on August 13, 2026.
2. American Heart Association. Electrocardiogram (ECG or EKG). Last reviewed February 24, 2025. Available at: https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/electrocardiogram-ecg-or-ekg. Accessed on July August 13, 2026.
3. Centers for Disease Control and Prevention. Heart disease facts. Last reviewed October 24, 2024. Available at: https://www.cdc.gov/heart-disease/data-research/facts-stats/?CDC_AAref_Val=https://www.cdc.gov/heartdisease/facts.htm. Accessed on August 13, 2026.
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/heart-tests. Accessed on August 13, 2026.
5. National Institutes of Health (NIH). National Heart, Lung, and Blood Institute. Coronary artery disease diagnosis. Updated December 27, 2024. Available at https://www.nhlbi.nih.gov/health/coronary-heart-disease/diagnosis. Accessed on August 13, 2026.

Resting Electrocardiogram (ECG)

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