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Medical Policy

Policy Num:       02.002.028
Policy Name:     Echocardiography
Policy ID:          [02.002.028][Ar L M+ P][0.00.00]

Last Review:      May 08, 2019
Next Review:      N/A
Issue:                May, 2019

Related Policies:

2.02.02 Doppler Echocardiography

ARCHIVED

Echocardiography

Popultation Reference No. Populations Interventions Comparators Outcomes
1 Individuals:
  • with new, recurrent, or worsening cardiac symptoms
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
2 Individuals:
  • without clear cardiac symptoms in the presence of an elevated cardiac troponin
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
3 Individuals:
  • with need of routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
4 Individuals:
  • with need of routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
5 Individuals:
  • with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test
     
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
6 Individuals:
  • with need to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
7 Individuals:
  • who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
8 Individuals:
  • with need of evaluating new, recurrent, or worsening left ventricular dysfunction/CHF
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
9 Individuals:
  • with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
10 Individuals:

  • undergoing non-cardiac surgery with  intermediate risk surgery (cardiac risk 1-5%), one or more cardiac risk factor(s) and inability to exercise adequately or high risk surgery (> 5% cardiac risk)

 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
11 Individuals:
  • Asymptomatic with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
12 Individuals:
  •  with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
13 Individuals:
  • with planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
14 Individuals:
  • to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc.
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
15 Individuals:
  • with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
16 Individuals:
  • with need of evaluation of valvular heart disease and detection and management of occult pulmonary hypertension. 
 Interventions of interest are:
  • Stress Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
17 Individuals:
  • with native valvular heart disease
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
18 Individuals:
  • with prosthetic heart valves (Mechanical and Bio-prostheses)
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
19 Individuals:
  • with endocarditis
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
20 Individuals:
  • with ventricular function and cardiomyopathies
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
21 Individuals:
  • with acute myocardial infarction and coronary insufficiency
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
22 Individuals:
  • with hypertensive cardiovascular disease
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
23 Individuals:
  • with cardiac transplant and rejection monitoring
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
24 Individuals:
  • with pericardial disease
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
25 Individuals:
  • with congenital heart disease
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
26 Individuals:
  • with cardiac tumors and masses
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
27 Individuals:
  • with critically ill and trauma patients
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
28 Individuals:
  • with suspected cardiac thrombi and embolic sources
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
29 Individuals:
  • with contrast echocardiography 
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
30 Individuals:
  • with cardiac tumors and masses
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
31 Individuals:
  • with diseases of aorta
 Interventions of interest are:
  • Transthoracic Echocardiography
 Comparators of interest are:
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
32 Individuals:
  • with need of examination of prosthetic heart valves, primarily mitral
 Interventions of interest are:
  • Transesophageal Echocardiogram
 Comparators of interest are:
  • Transthoracic Echocardiography
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
33 Individuals:
  • with Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions
 Interventions of interest are:
  • Transesophageal Echocardiogram
 Comparators of interest are:
  • Transthoracic Echocardiography
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
34 Individuals:
  • with Detection of:
    • aortic dissection
    • atrial septal defect
    • congenital heart disease
    • embolism or thrombosis, primarily involving left atrium
    • intracardiac foreign bodies, tumors or masses
    • mitral valve regurgitation
    • vegetative endocarditis
 Interventions of interest are:
  • Transesophageal Echocardiogram
 Comparators of interest are:
  • Transthoracic Echocardiography
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
35 Individuals:
  • with Intra-operative guide to left ventricular function
 Interventions of interest are:
  • Transesophageal Echocardiogram
 Comparators of interest are:
  • Transthoracic Echocardiography
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy
36 Individuals:
  • with inadequacy of transthoracic echo due to:
    • chest wall deformity
    • COPD
    • open heart or chest surgery
    • chest trauma
    • obesity
 Interventions of interest are:
  • Transesophageal Echocardiogram
 Comparators of interest are:
  • Transthoracic Echocardiography
  • Other diagnostic technologies available

Relevant outcomes include:

  • Evaluate cardiac function and anatomy

Summary

Echocardiography is a test of the heart using ultrasound.  It is a technology used universally to evaluate the cardiac anatomy and function.  The Transthoracic Echocardiography is performed by placing a transducer on the chest in the area of the heart.  In the Transesophageal Echocardiography the transducer is placed at the end of an endoscope that is inserted into the esophagus. Small transducers can be placed in the intravascular spaces through catheters, allowing the intravascular and anatomical registration of the vessel and its blood flow.

Cardiovascular stress testing, also called an exercise stress test (EST), exercise electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while the electrocardiogram, heart rate, and blood pressure are monitored. The same measurement may be obtained with the substitution of echocardiography for a standard ECG. Echocardiography is used to image cardiac structures and function and also flow direction and velocities within cardiac chambers and vessels. Usually these images are obtained from several positions on the chest wall and abdomen using a hand-held transducer.    

Stress Echocardiography 

 

 For individuals with new, recurrent, or worsening cardiac symptoms AND any of the following:

Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals without clear cardiac symptoms in the presence of an elevated cardiac troponin. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with need of routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with need of routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with need to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable . Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered . Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals w with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals undergoing non-cardiac surgery with  intermediate risk surgery (cardiac risk 1-5%), one or more cardiac risk factor(s) and inability to exercise adequately or high risk surgery (> 5% cardiac risk). Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals asymptomatic with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with need of evaluation of valvular heart disease and detection and management of occult pulmonary hypertension. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Transthoracic Echocardiography

For individuals with native valvular heart disease. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with prosthetic heart valves (Mechanical and Bio-prostheses) . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with endocarditis. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with ventricular function and cardiomyopathies . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with acute myocardial infarction and coronary insufficiency . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with hypertensive cardiovascular disease . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with cardiac transplant and rejection monitoring . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with pericardial disease. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with congenital heart disease . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with cardiac tumors and masses. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with critically ill and trauma patients . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with suspected cardiac thrombi and embolic sources . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with contrast echocardiography  . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with cardiac tumors and masses . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with diseases of aorta . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Transesophageal Echocardiography

For individuals  with need of examination of prosthetic heart valves, primarily mitral. Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions. Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with detection of aortic dissection, atrial septal defect, congenital heart disease, embolism or thrombosis, primarily involving left atrium, intracardiac foreign bodies, tumors or masses, mitral valve regurgitation, vegetative endocarditis . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with Intra-operative guide to left ventricular function . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals  with inadequacy of transthoracic echo due to chest wall deformity, COPD, open heart or chest surgery, chest trauma, obesity . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Objective

The objective of this policy is to determine, based on evidence review, the use of (1) Stress Echocardiography, (2) Transthoracic Echocardiography and (3) Transesophageal Echocardiography to improve the net health outcome in individuals with need of assesment for cardiac anatomy and fucntion anomalies.

Policy Statements

Stress Echocardiography

The following are considered medically necessary for  stress echo:

1. New, recurrent, or worsening cardiac symptoms AND any of the following:

2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin

3. Routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

4. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

5. Every 2 years in patients with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test

6. To assess for CAD in a patient with unexplained or drug-induced intraventricular condition disturbances

7. Prior anatomic imaging study (coronary angiogram or CCTA) to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging

8. Established CAD in a patient who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable

9. Evaluating new, recurrent, or worsening left ventricular dysfunction/CHF

10. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered

11. Pre-operative cardiac evaluation in patients undergoing non-cardiac surgery


12. Asymptomatic patients with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years

13. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year

14. Patients to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc.

15. Patients with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years

16. Stress echocardiography will be considered reasonable and necessary for the evaluation of valvular heart disease and detection and management of occult pulmonary hypertension. 

 

Transthoracic Echocardiography

A transthoracic echocardiography (TTE) will be considered medically reasonable and necessary for the following conditions:

1. Native Valvular Heart Disease
2. Prosthetic Heart Valves (Mechanical and Bio-prostheses)
3. Endocarditis
4. Ventricular Function and Cardiomyopathies
5. Acute Myocardial Infarction and Coronary Insufficiency
6. Hypertensive Cardiovascular Disease
7. Cardiac Transplant and Rejection Monitoring
8. Exposure to Cardiotoxic Agents (Chemotherapeutic and External)
9. Pericardial Disease
10. Congenital Heart Disease
11. Cardiac Tumors and Masses
12. Critically Ill and Trauma Patients
13. Suspected Cardiac Thrombi and Embolic Sources
14. Contrast echocardiography 
15. Diseases of Aorta
 

Transesophageal Echocardiography

Transesophageal echocardiogram will be considered medically necessary in any of the following circumstances:

Policy Guidelines

Stress Echocardiography

Stress testing with imaging can be performed with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine or adenosine analogs).

Stress echo and SPECT MPI are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, stress echo can provide additional information that is not obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction. 

When symptoms are present, and there is sufficient suspicion of heart disease to warrant cardiac evaluation, it is expected that the provider make a probability estimate of the likelihood of CAD prior to selecting testing. Assessment of coronary artery disease can be determined by the following:

Typical angina (definite): Substernal chest pain or discomfort that is provoked by exertion or emotional stress and relieved by rest and/or nitroglycerin.

Atypical angina (probable): Chest pain or discomfort (arm or jaw pain) that lacks one of the characteristics of definite or typical angina.

Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Anginal variants or equivalents: A manifestation of myocardial ischemia, which is perceived by patients to be (otherwise unexplained) dyspnea, unusual fatigue, more often seen in women and may be unassociated with chest pain.

Age, gender, and the character of the chest pain provide useful predictors of CAD. Refer to the following table for cardiac imaging guidelines.

Pre-test probability of CAD by age, gender, and symptoms:

Age (yr) Gender Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Non-Anginal Chest Pain Asymptomatic
≤39 Men Intermediate Intermediate Low Very Low
  Women Intermediate Very Low Very Low Very Low
40-49 Men High Intermediate Intermediate Low
  Women Intermediate Low Very Low Very Low
50-59 Men High Intermediate Intermediate Low
  Women Intermediate Intermediate Low Very Low
≥60 Men High Intermediate Intermediate Low
  Women High Intermediate Intermediate Low

High: Greater than 90% pre-test probability

Intermediate: Between 10% and 90% pre-test probability

Low: Between 5% and 10% pre-test probability

Very Low: Less than 5% pre-test probability

In summary, the choice of stress testing modality depends on many factors such as the patient's ability to exercise, the resting ECG, the clinical indication for performing the test, the patient's body habitus, and history of prior revascularization.

Transthoracic Echocardiography

Echocardiographic studies that are not reasonable and necessary to obtain clinically significant diagnostic or monitoring information are not indicated. The carrier will utilize the American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines (Class III) indications as a reference for such determinations.

Limited Capability Ultrasound Scanners

Some cardiac ultrasound machines have become increasingly compact and portable. Certain “hand carried” scanners are “full featured” and permit a skilled examiner to image and record permanent records of all of the tomographic images and Doppler data (Both color and spectral) needed to perform a complete transthoracic echocardiographic examination that may be quite comparable, in diagnostic value, to that obtained with a larger, “state of the art” instrument. In order to qualify as a valid echocardiographic service, the study must be done for an accepted clinical indication by a properly trained examiner and must include a permanent record of the findings, data sufficient to support the conclusions and an appropriate interpretation and written report. Such a study would meet the standards required for a complete echocardiographic examination, regardless of the size of the instrument used to perform the study.

Some small scanners have more limited capabilities and lack either the permanent recording capabilities or some of the functional capabilities needed to perform a complete examination. Such a study may be quite useful as an extension of the physical examination. However, an examination that does not meet the standards required for a complete diagnostic echocardiographic examination – whether performed with a “conventional” scanner or a limited capability ultrasound scanner – will not be recognized as a valid echocardiographic service and will be non-covered. 

Training Requirements:

While it is not the Carrier’s intention or jurisdiction to credential providers, a satisfactory level of competence is expected from providers who submit claims for services rendered. It is well known that substandard studies often lead to preventable repetition of studies and overutilization of services.

The acceptable levels of competence are outlined as follows:

For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions: 

  1. The service is performed by a physician; or
  2. The service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or 
  3. The service is performed at a laboratory (e.g. office, IDTF), credentialed by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL).

For the professional portion, an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements:

  1. The physician is board certified in Cardiovascular Diseases; or
  2. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document; or
  3. The physician provides the interpretation in conjunction with a study that is performed at a laboratory that is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories and that is subject to such laboratory’s quality assurance policies and procedures; or
  4. The physician has staff privileges to interpret echocardiograms at a hospital that participates in the Medicare program.

The submission of claims for echocardiography will be considered an attestation that both the technical and professional components of the service were provided within the context of the above stated credentials. However, a grace period of two years will be allowed for providers to acquire the necessary training.

All echocardiography services require a referring or an ordering physician.

However, if the facility has a documented process for grand-fathering experienced technicians who have performed the services referenced in this LCD (a process addressing years of service and experience with number of supervised cases), this documentation should be available upon request; otherwise the provider must have documentation available upon request which indicates that the technician meets the credentialing requirements as stated above or is in the process of obtaining this credentialing.

 

Transesophageal Echocardiography

Transesophageal Echocardiography (TEE) is a cardiac diagnostic procedure in which a modified endoscope, with an ultrasound transducer, is passed into the esophagus and/or stomach in order to obtain 2-D/3D echo images and spectral and color doppler information about the heart and its great vessels.

Transesophageal Echocardiography (TEE) imaging is a viable alternative when transthoracic imaging is problematic or difficult. In many instances, abnormalities can be displayed that are missed with standard diagnostic techniques, and the images displayed are often of superior quality because of the high-resolution probes that can be used.

Clinical situations in which TEE should be considered as the initial test include :

●Suspected acute aortic pathology (ie, dissection, transsection, intramural hematoma)

●Suspected prosthetic valve dysfunction (thrombus, pannus ingrowth, vegetation, or regurgitation)

●Suspected complications of endocarditis (eg, fistula, abscess)

●Evaluation for left atrial/LAA thrombus in a patient with atrial fibrillation/atrial flutter to facilitate clinical decision making regarding anticoagulation, cardioversion, or ablation

●Evaluation of source of embolism in a young (<50 years) patient for whom a TEE would be performed if the TTE was normal

Benefit Application

BlueCard/National Account Issues

N/A

Background

Echocardiography enables evaluation of cardiac function at rest, during pharmacologic stress, and during or immediately following dynamic exercise. Exercise two-dimensional (2D) imaging is used primarily to detect the presence and extent of coronary artery disease by provoking regional ischemia with resulting wall motion abnormalities. The addition of exercise Doppler permits evaluation of valvular function, pulmonary artery pressure, left ventricular outflow tract gradients, and global ventricular systolic and diastolic function.

Stress echocardiography can be accomplished using either exercise (treadmill or bicycle) or pharmacologic agents (predominantly dobutamine) as the stress mechanism. Echocardiographic contrast agents may be useful in enhancing endocardial border definition when two or more segments of the left ventricle are not well visualized.

There are several specific indications for stress echocardiography:

●Evaluation of patients with known or suspected coronary artery disease.

●Assessment of myocardial viability.

●Evaluation of dyspnea of possible cardiac origin.n for pulmonary hypertension, as pulmonary artery systolic pressure can be estimated at rest and with exercise. 

●Evaluation of mitral valve disease, including mitral stenosis and mitral regurgitation.

●Evaluation of aortic stenosis. Stress echocardiography may be reasonable and helpful in patients with low gradient aortic stenosis or asymptomatic aortic stenosis. 

●Evaluation of left ventricular outflow tract gradients, mitral regurgitation, and pulmonary hypertension in patients with hypertrophic cardiomyopathy.

CONTRAINDICATIONS — Contraindications to exercise and pharmacologic stress echocardiography are the same as those for standard exercise electrocardiographic (ECG) testing. Contraindications to dobutamine stress echocardiography include tachyarrhythmias and systemic hypertension.

Tissue Doppler echocardiography (TDE) has become an established component of the diagnostic ultrasound examination; it permits an assessment of myocardial motion using Doppler ultrasound imaging, often with color coding. The technique uses frequency shifts of ultrasound waves to calculate myocardial velocity; this is similar to routine Doppler ultrasound to assess blood flow, but its technological features focus on lower velocity frequency shifts.

Although Doppler ultrasound has been in widespread clinical use to assess intracardiac blood flow and noninvasive hemodynamics for many years, interest in TDE increased significantly when the color-coded TDE method was introduced . Routine echocardiographic assessment of regional left ventricular (LV) wall motion is subjective because it is determined by visual determination of endocardial excursion and wall thickening. TDE offers the promise of an objective measure to quantify regional and global LV function through the assessment of myocardial velocity data.

Regulatory Status

N/A

Rationale

Stress Echocardiography

Cardiovascular stress testing, also called an exercise stress test (EST), exercise electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while the electrocardiogram, heart rate, and blood pressure are monitored. The same measurement may be obtained with the substitution of echocardiography for a standard ECG. Echocardiography is used to image cardiac structures and function and also flow direction and velocities within cardiac chambers and vessels. Usually these images are obtained from several positions on the chest wall and abdomen using a hand-held transducer.

In many instances, exercise testing (without imaging) may be combined with imaging procedures, such as myocardial perfusion imaging, radionuclide ventriculography, echocardiography, or other imaging procedures.

There are 3 principle types of stress tests which do not involve the measurement of radio-labelled distribution within the body. These include:

The main task of Nuclear Cardiology and Nuclear Medicine is not the representation of anatomy, as in traditional Diagnostic Radiology; rather, it is the non-invasive visualization of functional, metabolic processes. In diagnostic Nuclear Medicine, the subject first incorporates tracer amounts of a radioactively-labelled molecule. Once the tracer molecule is properly distributed inside the body, imaging techniques visualize the metabolism of the substance by measuring the distribution of the radioactively-labelled molecule through externally emitted radiation. 

Population Reference No. 1 Policy Statement

 For individuals with new, recurrent, or worsening cardiac symptoms AND any of the following:

Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

 

Population Reference No. 1 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 2 Policy Statement

For individuals without clear cardiac symptoms in the presence of an elevated cardiac troponin. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 2 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 3 Policy Statement

For individuals with need of routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 3 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 4 Policy Statement

For individuals with need of routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 4 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 5 Policy Statement

For individuals with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 5 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 6 Policy Statement

For individuals with need to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 6 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 7 Policy Statement

For individuals who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable . Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 7 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 8 Policy Statement

For individuals with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered . Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 8 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 9 Policy Statement

For individuals w with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 9 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 10 Policy Statement

For individuals undergoing non-cardiac surgery with  intermediate risk surgery (cardiac risk 1-5%), one or more cardiac risk factor(s) and inability to exercise adequately or high risk surgery (> 5% cardiac risk). Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 10 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 11 Policy Statement

For individuals asymptomatic with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 11 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 12 Policy Statement

For individuals  with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 12 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 13 Policy Statement

For individuals  with planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 13 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 14 Policy Statement

For individuals to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 14 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 15 Policy Statement

For individuals with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 15 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 16 Policy Statement

For individuals with need of evaluation of valvular heart disease and detection and management of occult pulmonary hypertension. Intervention of interest is stress echocardiography. Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 16 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Transthoracic Echocardiography

Population Reference No. 17 Policy Statement

For individuals with native valvular heart disease. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 17 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 18 Policy Statement

For individuals with prosthetic heart valves (Mechanical and Bio-prostheses) . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 18 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 19 Policy Statement

For individuals with endocarditis. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 19 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 20 Policy Statement

For individuals with ventricular function and cardiomyopathies . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 20 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 21 Policy Statement

For individuals with acute myocardial infarction and coronary insufficiency . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 21 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 22 Policy Statement

For individuals with hypertensive cardiovascular disease . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 22 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 23 Policy Statement

For individuals with cardiac transplant and rejection monitoring . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 23 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 24 Policy Statement

For individuals with pericardial disease. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 24  Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 25 Policy Statement

For individuals with congenital heart disease . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 25  Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 26 Policy Statement

For individuals with cardiac tumors and masses. Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 26 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 27 Policy Statement

For individuals with critically ill and trauma patients . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 27 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 28 Policy Statement

For individuals with suspected cardiac thrombi and embolic sources . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 28  Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 29 Policy Statement

For individuals with contrast echocardiography  . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 29  Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 30 Policy Statement

For individuals with cardiac tumors and masses . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 30 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 31 Policy Statement

For individuals with diseases of aorta . Intervention of interest is Transthoracic Echocardiography . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 31 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Transesophageal Echocardiography

Population Reference No. 32 Policy Statement

For individuals  with need of examination of prosthetic heart valves, primarily mitral. Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 32 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 33 Policy Statement

For individuals  with Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions. Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 33 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 34 Policy Statement

For individuals  with detection of aortic dissection, atrial septal defect, congenital heart disease, embolism or thrombosis, primarily involving left atrium, intracardiac foreign bodies, tumors or masses, mitral valve regurgitation, vegetative endocarditis . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 34 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 35 Policy Statement

For individuals  with Intra-operative guide to left ventricular function . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 35 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Population Reference No. 36 Policy Statement

For individuals  with inadequacy of transthoracic echo due to chest wall deformity, COPD, open heart or chest surgery, chest trauma, obesity . Intervention of interest is Transesophageal Echocardiogram . Comparators of interest are other diagnostic technologies available. Relevant outcomes include to evaluate cardiac function and anatomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Population Reference No. 36 Policy Statement [X] Medically Necessary [ ] Investigational [ ] Not Medically Necessary

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

Medicare have three local coverage determinations for echocardiography: L33768 for TTE, L33756 for TEE and L36209 mentions Stress Echo.

References

[1] 1. American College of Radiology. ACR Appropriateness criteria. Acute nonspecific chest pain–low probability of coronary artery disease. Date of origin: 1998. Last review date: 2011.Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[2] 2. American College of Radiology. ACR Appropriateness criteria. Acute chest pain–suspected aortic dissection. Date of origin: 1998. Last review date: 2011. Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.asp.x

[3] 3. American College of Radiology. ACR Appropriateness criteria. Acute chest pain–suspected pulmonary embolism. Date of origin: 1995. Last review date: 2011. Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[4] 4. American College of Radiology. ACR Appropriateness criteria. Chest pain–suggestion of acute coronary syndrome. Date of origin: 1995. Last review date: 2010.Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[5] 5. American College of Radiology. ACR Appropriateness criteria. Chronic chest pain–high probability of coronary artery disease. Date of origin: 1995. Last review date: 2010.Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[6] 6. American College of Radiology. ACR Appropriateness criteria. Chronic chest pain–low to intermediate probability of coronary artery disease. Date of origin: 1998. Last review date: 2008.Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[7] 7. American College of Radiology. ACR Appropriateness criteria. Dyspnea, suspected cardiac origin. Date of origin: 1995. Last review date: 2010. Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[8] 8. American College of Radiology. ACR Appropriateness criteria. Suspected infective endocarditis. Date of origin: 1998. Last review date: 2011.Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[9] 9. American College of Radiology. ACR Appropriateness criteria. Suspected congenital heart disease in the adult. Date of origin: 1998. Last review date: 2011 .Accessed Apr 11, 2012. Available at URL address: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.

[10] CMS Local Coverage Determination L33768 .

[11] CMS Local Coverage Determination L33756 .

[12] CMS Local Coverage Determination L36209 .

Codes

Codes Number Description
CPT 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete
  93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study
  93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography
  93307 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography
  93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study
  93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
  93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only
  93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only
  93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
  93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only
  93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only
  93318 Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis
  +93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete
  +93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)
  +93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)
  93350 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report;
  93351 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional
  93352 Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure)
  93355 Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D
ICD-10-CM   Medical Necessity for Stress Echocardiography
  I01.0 - I01.9 Acute rheumatic pericarditis - Acute rheumatic heart disease, unspecified
  I02.0 Rheumatic chorea with heart involvement
  I05.0 - I05.9 Rheumatic mitral stenosis - Rheumatic mitral valve disease, unspecified
  I06.0 - I06.9 Rheumatic aortic stenosis - Rheumatic aortic valve disease, unspecified
  I07.0 - I07.9 Rheumatic tricuspid stenosis - Rheumatic tricuspid valve disease, unspecified
  I08.0 - I08.9 Rheumatic disorders of both mitral and aortic valves - Rheumatic multiple valve disease, unspecified
  I09.1 Rheumatic diseases of endocardium, valve unspecified
  I09.81 Rheumatic heart failure
  I09.89 Other specified rheumatic heart diseases
  I09.9 Rheumatic heart disease, unspecified
  I11.0 - I11.9 Hypertensive heart disease with heart failure - Hypertensive heart disease without heart failure
  I13.0 - I13.2 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease - Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
  I20.0 - I20.9 Unstable angina - Angina pectoris, unspecified
  I21.01 - I21.9 ST elevation (STEMI) myocardial infarction involving left main coronary artery - Acute myocardial infarction, unspecified
  I21.A1 - I21.A9 Myocardial infarction type 2 - Other myocardial infarction type
  I22.0 - I22.9 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall - Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
  I24.0 Acute coronary thrombosis not resulting in myocardial infarction
  I24.1 Dressler's syndrome
  I24.8 Other forms of acute ischemic heart disease
  I24.9 Acute ischemic heart disease, unspecified
  I25.10 - I25.9 Atherosclerotic heart disease of native coronary artery without angina pectoris - Chronic ischemic heart disease, unspecified
  I26.01 - I26.99 Septic pulmonary embolism with acute cor pulmonale - Other pulmonary embolism without acute cor pulmonale
  I27.0 - I27.9 Primary pulmonary hypertension - Pulmonary heart disease, unspecified
  I34.0 - I34.9 Nonrheumatic mitral (valve) insufficiency - Nonrheumatic mitral valve disorder, unspecified
  I35.0 - I35.9 Nonrheumatic aortic (valve) stenosis - Nonrheumatic aortic valve disorder, unspecified
  I36.0 - I36.9 Nonrheumatic tricuspid (valve) stenosis - Nonrheumatic tricuspid valve disorder, unspecified
  I37.0 - I37.9 Nonrheumatic pulmonary valve stenosis - Nonrheumatic pulmonary valve disorder, unspecified
  I44.30 - I45.6 Unspecified atrioventricular block - Pre-excitation syndrome
  I48.0 Paroxysmal atrial fibrillation
  I48.2 Chronic atrial fibrillation
  I48.91 Unspecified atrial fibrillation
  I50.1 - I50.9 Left ventricular failure, unspecified - Heart failure, unspecified
  I70.211 - I70.269 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg - Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
  I70.92 Chronic total occlusion of artery of the extremities
  R01.0 - R01.2 Benign and innocent cardiac murmurs - Other cardiac sounds
  R06.00 - R06.09 Dyspnea, unspecified - Other forms of dyspnea
  R06.2 - R06.4 Wheezing - Hyperventilation
  R06.81 - R06.9 Apnea, not elsewhere classified - Unspecified abnormalities of breathing
  R55 Syncope and collapse
  R94.31 Abnormal electrocardiogram [ECG] [EKG]
  R94.39 Abnormal result of other cardiovascular function study
  T36.0X5A - T36.0X5S Adverse effect of penicillins, initial encounter - Adverse effect of penicillins, sequela
  T36.1X5A - T36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter - Adverse effect of cephalosporins and other beta-lactam antibiotics, sequela
  T36.2X5A - T36.2X5S Adverse effect of chloramphenicol group, initial encounter - Adverse effect of chloramphenicol group, sequela
  T36.3X5A - T36.3X5S Adverse effect of macrolides, initial encounter - Adverse effect of macrolides, sequela
  T36.4X5A - T36.4X5S Adverse effect of tetracyclines, initial encounter - Adverse effect of tetracyclines, sequela
  T36.5X5A - T36.5X5S Adverse effect of aminoglycosides, initial encounter - Adverse effect of aminoglycosides, sequela
  T36.6X5A - T36.6X5S Adverse effect of rifampicins, initial encounter - Adverse effect of rifampicins, sequela
  T36.7X5A - T36.7X5S Adverse effect of antifungal antibiotics, systemically used, initial encounter - Adverse effect of antifungal antibiotics, systemically used, sequela
  T36.8X5A - T36.8X5S Adverse effect of other systemic antibiotics, initial encounter - Adverse effect of other systemic antibiotics, sequela
  T36.95XA - T36.95XS Adverse effect of unspecified systemic antibiotic, initial encounter - Adverse effect of unspecified systemic antibiotic, sequela
  T37.0X5A - T37.0X5S Adverse effect of sulfonamides, initial encounter - Adverse effect of sulfonamides, sequela
  T37.1X5A - T37.1X5S Adverse effect of antimycobacterial drugs, initial encounter - Adverse effect of antimycobacterial drugs, sequela
  T37.2X5A - T37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter - Adverse effect of antimalarials and drugs acting on other blood protozoa, sequela
  T37.3X5A - T37.3X5S Adverse effect of other antiprotozoal drugs, initial encounter - Adverse effect of other antiprotozoal drugs, sequela
  T37.4X5A - T37.4X5S Adverse effect of anthelminthics, initial encounter - Adverse effect of anthelminthics, sequela
  T37.5X5A - T37.5X5S Adverse effect of antiviral drugs, initial encounter - Adverse effect of antiviral drugs, sequela
  T37.8X5A - T37.8X5S Adverse effect of other specified systemic anti-infectives and antiparasitics, initial encounter - Adverse effect of other specified systemic anti-infectives and antiparasitics, sequela
  T37.95XA - T37.95XS Adverse effect of unspecified systemic anti-infective and antiparasitic, initial encounter - Adverse effect of unspecified systemic anti-infective and antiparasitic, sequela
  T38.0X5A - T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, initial encounter - Adverse effect of glucocorticoids and synthetic analogues, sequela
  T38.1X5A - T38.1X5S Adverse effect of thyroid hormones and substitutes, initial encounter - Adverse effect of thyroid hormones and substitutes, sequela
  T38.2X5A - T38.2X5S Adverse effect of antithyroid drugs, initial encounter - Adverse effect of antithyroid drugs, sequela
  T38.4X5A - T38.4X5S Adverse effect of oral contraceptives, initial encounter - Adverse effect of oral contraceptives, sequela
  T38.5X5A - T38.5X5S Adverse effect of other estrogens and progestogens, initial encounter - Adverse effect of other estrogens and progestogens, sequela
  T38.6X5A - T38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter - Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, sequela
  T38.7X5A - T38.7X5S Adverse effect of androgens and anabolic congeners, initial encounter - Adverse effect of androgens and anabolic congeners, sequela
  T38.805A - T38.805S Adverse effect of unspecified hormones and synthetic substitutes, initial encounter - Adverse effect of unspecified hormones and synthetic substitutes, sequela
  T38.815A - T38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounter - Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequela
  T38.895A - T38.895S Adverse effect of other hormones and synthetic substitutes, initial encounter - Adverse effect of other hormones and synthetic substitutes, sequela
  T38.905A - T38.905S Adverse effect of unspecified hormone antagonists, initial encounter - Adverse effect of unspecified hormone antagonists, sequela
  T38.995A - T38.995S Adverse effect of other hormone antagonists, initial encounter - Adverse effect of other hormone antagonists, sequela
  T39.015A - T39.015S Adverse effect of aspirin, initial encounter - Adverse effect of aspirin, sequela
  T39.095A - T39.095S Adverse effect of salicylates, initial encounter - Adverse effect of salicylates, sequela
  T39.1X5A - T39.1X5S Adverse effect of 4-Aminophenol derivatives, initial encounter - Adverse effect of 4-Aminophenol derivatives, sequela
  T39.2X5A - T39.2X5S Adverse effect of pyrazolone derivatives, initial encounter - Adverse effect of pyrazolone derivatives, sequela
  T39.315A - T39.315S Adverse effect of propionic acid derivatives, initial encounter - Adverse effect of propionic acid derivatives, sequela
  T39.395A - T39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter - Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], sequela
  T39.4X5A - T39.4X5S Adverse effect of antirheumatics, not elsewhere classified, initial encounter - Adverse effect of antirheumatics, not elsewhere classified, sequela
  T39.8X5A - T39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, initial encounter - Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, sequela
  T39.95XA - T39.95XS Adverse effect of unspecified nonopioid analgesic, antipyretic and antirheumatic, initial encounter - Adverse effect of unspecified nonopioid analgesic, antipyretic and antirheumatic, sequela
  T40.0X5A - T40.0X5S Adverse effect of opium, initial encounter - Adverse effect of opium, sequela
  T40.2X5A - T40.2X5S Adverse effect of other opioids, initial encounter - Adverse effect of other opioids, sequela
  T40.3X5A - T40.3X5S Adverse effect of methadone, initial encounter - Adverse effect of methadone, sequela
  T40.4X5A - T40.4X5S Adverse effect of other synthetic narcotics, initial encounter - Adverse effect of other synthetic narcotics, sequela
  T40.5X5A - T40.5X5S Adverse effect of cocaine, initial encounter - Adverse effect of cocaine, sequela
  T40.605A - T40.605S Adverse effect of unspecified narcotics, initial encounter - Adverse effect of unspecified narcotics, sequela
  T40.695A - T40.695S Adverse effect of other narcotics, initial encounter - Adverse effect of other narcotics, sequela
  T40.7X5A - T40.7X5S Adverse effect of cannabis (derivatives), initial encounter - Adverse effect of cannabis (derivatives), sequela
  T40.905A - T40.905S Adverse effect of unspecified psychodysleptics [hallucinogens], initial encounter - Adverse effect of unspecified psychodysleptics [hallucinogens], sequela
  T40.995A - T40.995S Adverse effect of other psychodysleptics [hallucinogens], initial encounter - Adverse effect of other psychodysleptics [hallucinogens], sequela
  T41.5X5A - T41.5X5S Adverse effect of therapeutic gases, initial encounter - Adverse effect of therapeutic gases, sequela
  T42.0X5A - T42.0X5S Adverse effect of hydantoin derivatives, initial encounter - Adverse effect of hydantoin derivatives, sequela
  T42.1X5A - T42.1X5S Adverse effect of iminostilbenes, initial encounter - Adverse effect of iminostilbenes, sequela
  T42.2X5A - T42.2X5S Adverse effect of succinimides and oxazolidinediones, initial encounter - Adverse effect of succinimides and oxazolidinediones, sequela
  T42.3X5A - T42.3X5S Adverse effect of barbiturates, initial encounter - Adverse effect of barbiturates, sequela
  T42.4X5A - T42.4X5S Adverse effect of benzodiazepines, initial encounter - Adverse effect of benzodiazepines, sequela
  T42.5X5A - T42.5X5S Adverse effect of mixed antiepileptics, initial encounter - Adverse effect of mixed antiepileptics, sequela
  T42.6X5A - T42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter - Adverse effect of other antiepileptic and sedative-hypnotic drugs, sequela
  T42.75XA - T42.75XS Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, initial encounter - Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, sequela
  T42.8X5A - T42.8X5S Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, initial encounter - Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, sequela
  T43.015A - T43.015S Adverse effect of tricyclic antidepressants, initial encounter - Adverse effect of tricyclic antidepressants, sequela
  T43.025A - T43.025S Adverse effect of tetracyclic antidepressants, initial encounter - Adverse effect of tetracyclic antidepressants, sequela
  T43.1X5A - T43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial encounter - Adverse effect of monoamine-oxidase-inhibitor antidepressants, sequela
  T43.205A - T43.205S Adverse effect of unspecified antidepressants, initial encounter - Adverse effect of unspecified antidepressants, sequela
  T43.215A - T43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter - Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequela
  T43.225A - T43.225S Adverse effect of selective serotonin reuptake inhibitors, initial encounter - Adverse effect of selective serotonin reuptake inhibitors, sequela
  T43.295A - T43.295S Adverse effect of other antidepressants, initial encounter - Adverse effect of other antidepressants, sequela
  T43.3X5A - T43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, initial encounter - Adverse effect of phenothiazine antipsychotics and neuroleptics, sequela
  T43.4X5A - T43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, initial encounter - Adverse effect of butyrophenone and thiothixene neuroleptics, sequela
  T43.505A - T43.505S Adverse effect of unspecified antipsychotics and neuroleptics, initial encounter - Adverse effect of unspecified antipsychotics and neuroleptics, sequela
  T43.595A - T43.595S Adverse effect of other antipsychotics and neuroleptics, initial encounter - Adverse effect of other antipsychotics and neuroleptics, sequela
  T43.605A - T43.605S Adverse effect of unspecified psychostimulants, initial encounter - Adverse effect of unspecified psychostimulants, sequela
  T43.615A - T43.615S Adverse effect of caffeine, initial encounter - Adverse effect of caffeine, sequela
  T43.625A - T43.625S Adverse effect of amphetamines, initial encounter - Adverse effect of amphetamines, sequela
  T43.635A - T43.635S Adverse effect of methylphenidate, initial encounter - Adverse effect of methylphenidate, sequela
  T43.695A - T43.695S Adverse effect of other psychostimulants, initial encounter - Adverse effect of other psychostimulants, sequela
  T43.8X5A - T43.8X5S Adverse effect of other psychotropic drugs, initial encounter - Adverse effect of other psychotropic drugs, sequela
  T43.95XA - T43.95XS Adverse effect of unspecified psychotropic drug, initial encounter - Adverse effect of unspecified psychotropic drug, sequela
  T44.0X5A - T44.0X5S Adverse effect of anticholinesterase agents, initial encounter - Adverse effect of anticholinesterase agents, sequela
  T44.1X5A - T44.1X5S Adverse effect of other parasympathomimetics [cholinergics], initial encounter - Adverse effect of other parasympathomimetics [cholinergics], sequela
  T44.2X5A - T44.2X5S Adverse effect of ganglionic blocking drugs, initial encounter - Adverse effect of ganglionic blocking drugs, sequela
  T44.3X5A - T44.3X5S Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, initial encounter - Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, sequela
  T44.4X5A - T44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, initial encounter - Adverse effect of predominantly alpha-adrenoreceptor agonists, sequela
  T44.5X5A - T44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter - Adverse effect of predominantly beta-adrenoreceptor agonists, sequela
  T44.6X5A - T44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, initial encounter - Adverse effect of alpha-adrenoreceptor antagonists, sequela
  T44.7X5A - T44.7X5S Adverse effect of beta-adrenoreceptor antagonists, initial encounter - Adverse effect of beta-adrenoreceptor antagonists, sequela
  T44.8X5A - T44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter - Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, sequela
  T44.905A - T44.905S Adverse effect of unspecified drugs primarily affecting the autonomic nervous system, initial encounter - Adverse effect of unspecified drugs primarily affecting the autonomic nervous system, sequela
  T44.995A - T44.995S Adverse effect of other drug primarily affecting the autonomic nervous system, initial encounter - Adverse effect of other drug primarily affecting the autonomic nervous system, sequela
  T45.0X5A - T45.0X5S Adverse effect of antiallergic and antiemetic drugs, initial encounter - Adverse effect of antiallergic and antiemetic drugs, sequela
  T45.1X1A - T45.1X1S Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter - Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), sequela
  T45.1X5A - T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter - Adverse effect of antineoplastic and immunosuppressive drugs, sequela
  T45.2X5A - T45.2X5S Adverse effect of vitamins, initial encounter - Adverse effect of vitamins, sequela
  T45.3X5A - T45.3X5S Adverse effect of enzymes, initial encounter - Adverse effect of enzymes, sequela
  T45.4X5A - T45.4X5S Adverse effect of iron and its compounds, initial encounter - Adverse effect of iron and its compounds, sequela
  T45.515A - T45.515S Adverse effect of anticoagulants, initial encounter - Adverse effect of anticoagulants, sequela
  T45.525A - T45.525S Adverse effect of antithrombotic drugs, initial encounter - Adverse effect of antithrombotic drugs, sequela
  T45.605A - T45.605S Adverse effect of unspecified fibrinolysis-affecting drugs, initial encounter - Adverse effect of unspecified fibrinolysis-affecting drugs, sequela
  T45.615A - T45.615S Adverse effect of thrombolytic drugs, initial encounter - Adverse effect of thrombolytic drugs, sequela
  T45.625A - T45.625S Adverse effect of hemostatic drug, initial encounter - Adverse effect of hemostatic drug, sequela
  T45.695A - T45.695S Adverse effect of other fibrinolysis-affecting drugs, initial encounter - Adverse effect of other fibrinolysis-affecting drugs, sequela
  T45.7X5A - T45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounter - Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, sequela
  T45.8X5A - T45.8X5S Adverse effect of other primarily systemic and hematological agents, initial encounter - Adverse effect of other primarily systemic and hematological agents, sequela
  T45.95XA - T45.95XS Adverse effect of unspecified primarily systemic and hematological agent, initial encounter - Adverse effect of unspecified primarily systemic and hematological agent, sequela
  T46.0X5A - T46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounter - Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequela
  T46.1X5A - T46.1X5S Adverse effect of calcium-channel blockers, initial encounter - Adverse effect of calcium-channel blockers, sequela
  T46.2X5A - T46.2X5S Adverse effect of other antidysrhythmic drugs, initial encounter - Adverse effect of other antidysrhythmic drugs, sequela
  T46.3X5A - T46.3X5S Adverse effect of coronary vasodilators, initial encounter - Adverse effect of coronary vasodilators, sequela
  T46.4X5A - T46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter - Adverse effect of angiotensin-converting-enzyme inhibitors, sequela
  T46.5X5A - T46.5X5S Adverse effect of other antihypertensive drugs, initial encounter - Adverse effect of other antihypertensive drugs, sequela
  T46.6X5A - T46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounter - Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequela
  T46.7X5A - T46.7X5S Adverse effect of peripheral vasodilators, initial encounter - Adverse effect of peripheral vasodilators, sequela
  T46.8X5A - T46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents, initial encounter - Adverse effect of antivaricose drugs, including sclerosing agents, sequela
  T46.905A - T46.905S Adverse effect of unspecified agents primarily affecting the cardiovascular system, initial encounter - Adverse effect of unspecified agents primarily affecting the cardiovascular system, sequela
  T46.995A - T46.995S Adverse effect of other agents primarily affecting the cardiovascular system, initial encounter - Adverse effect of other agents primarily affecting the cardiovascular system, sequela
  T47.0X5A - T47.0X5S Adverse effect of histamine H2-receptor blockers, initial encounter - Adverse effect of histamine H2-receptor blockers, sequela
  T47.1X5A - T47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, initial encounter - Adverse effect of other antacids and anti-gastric-secretion drugs, sequela
  T47.2X5A - T47.2X5S Adverse effect of stimulant laxatives, initial encounter - Adverse effect of stimulant laxatives, sequela
  T47.3X5A - T47.3X5S Adverse effect of saline and osmotic laxatives, initial encounter - Adverse effect of saline and osmotic laxatives, sequela
  T47.4X5A - T47.4X5S Adverse effect of other laxatives, initial encounter - Adverse effect of other laxatives, sequela
  T47.5X5A - T47.5X5S Adverse effect of digestants, initial encounter - Adverse effect of digestants, sequela
  T47.6X5A - T47.6X5S Adverse effect of antidiarrheal drugs, initial encounter - Adverse effect of antidiarrheal drugs, sequela
  T47.7X5A - T47.7X5S Adverse effect of emetics, initial encounter - Adverse effect of emetics, sequela
  T47.8X5A - T47.8X5S Adverse effect of other agents primarily affecting gastrointestinal system, initial encounter - Adverse effect of other agents primarily affecting gastrointestinal system, sequela
  T47.95XA - T47.95XS Adverse effect of unspecified agents primarily affecting the gastrointestinal system, initial encounter - Adverse effect of unspecified agents primarily affecting the gastrointestinal system, sequela
  T48.0X5A - T48.0X5S Adverse effect of oxytocic drugs, initial encounter - Adverse effect of oxytocic drugs, sequela
  T48.1X5A - T48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], initial encounter - Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], sequela
  T48.205A - T48.205S Adverse effect of unspecified drugs acting on muscles, initial encounter - Adverse effect of unspecified drugs acting on muscles, sequela
  T48.295A - T48.295S Adverse effect of other drugs acting on muscles, initial encounter - Adverse effect of other drugs acting on muscles, sequela
  T48.3X5A - T48.3X5S Adverse effect of antitussives, initial encounter - Adverse effect of antitussives, sequela
  T48.4X5A - T48.4X5S Adverse effect of expectorants, initial encounter - Adverse effect of expectorants, sequela
  T48.5X5A - T48.5X5S Adverse effect of other anti-common-cold drugs, initial encounter - Adverse effect of other anti-common-cold drugs, sequela
  T48.6X5A - T48.6X5S Adverse effect of antiasthmatics, initial encounter - Adverse effect of antiasthmatics, sequela
  T48.905A - T48.905S Adverse effect of unspecified agents primarily acting on the respiratory system, initial encounter - Adverse effect of unspecified agents primarily acting on the respiratory system, sequela
  T48.995A - T48.995S Adverse effect of other agents primarily acting on the respiratory system, initial encounter - Adverse effect of other agents primarily acting on the respiratory system, sequela
  T49.0X5A - T49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounter - Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, sequela
  T49.1X5A - T49.1X5S Adverse effect of antipruritics, initial encounter - Adverse effect of antipruritics, sequela
  T49.2X5A - T49.2X5S Adverse effect of local astringents and local detergents, initial encounter - Adverse effect of local astringents and local detergents, sequela
  T49.3X5A - T49.3X5S Adverse effect of emollients, demulcents and protectants, initial encounter - Adverse effect of emollients, demulcents and protectants, sequela
  T49.4X5A - T49.4X5S Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and preparations, initial encounter - Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and preparations, sequela
  T49.5X5A - T49.5X5S Adverse effect of ophthalmological drugs and preparations, initial encounter - Adverse effect of ophthalmological drugs and preparations, sequela
  T49.6X5A - T49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, initial encounter - Adverse effect of otorhinolaryngological drugs and preparations, sequela
  T49.7X5A - T49.7X5S Adverse effect of dental drugs, topically applied, initial encounter - Adverse effect of dental drugs, topically applied, sequela
  T49.8X5A - T49.8X5S Adverse effect of other topical agents, initial encounter - Adverse effect of other topical agents, sequela
  T49.95XA - T49.95XS Adverse effect of unspecified topical agent, initial encounter - Adverse effect of unspecified topical agent, sequela
  T50.0X5A - T50.0X5S Adverse effect of mineralocorticoids and their antagonists, initial encounter - Adverse effect of mineralocorticoids and their antagonists, sequela
  T50.1X5A - T50.1X5S Adverse effect of loop [high-ceiling] diuretics, initial encounter - Adverse effect of loop [high-ceiling] diuretics, sequela
  T50.2X5A - T50.2X5S Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter - Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, sequela
  T50.3X5A - T50.3X5S Adverse effect of electrolytic, caloric and water-balance agents, initial encounter - Adverse effect of electrolytic, caloric and water-balance agents, sequela
  T50.4X5A - T50.4X5S Adverse effect of drugs affecting uric acid metabolism, initial encounter - Adverse effect of drugs affecting uric acid metabolism, sequela
  T50.5X5A - T50.5X5S Adverse effect of appetite depressants, initial encounter - Adverse effect of appetite depressants, sequela
  T50.6X5A - T50.6X5S Adverse effect of antidotes and chelating agents, initial encounter - Adverse effect of antidotes and chelating agents, sequela
  T50.7X5A - T50.7X5S Adverse effect of analeptics and opioid receptor antagonists, initial encounter - Adverse effect of analeptics and opioid receptor antagonists, sequela
  T50.8X5A - T50.8X5S Adverse effect of diagnostic agents, initial encounter - Adverse effect of diagnostic agents, sequela
  T50.A15A - T50.A15S Adverse effect of pertussis vaccine, including combinations with a pertussis component, initial encounter - Adverse effect of pertussis vaccine, including combinations with a pertussis component, sequela
  T50.A25A - T50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component, initial encounter - Adverse effect of mixed bacterial vaccines without a pertussis component, sequela
  T50.A95A - T50.A95S Adverse effect of other bacterial vaccines, initial encounter - Adverse effect of other bacterial vaccines, sequela
  T50.B15A - T50.B15S Adverse effect of smallpox vaccines, initial encounter - Adverse effect of smallpox vaccines, sequela
  T50.B95A - T50.B95S Adverse effect of other viral vaccines, initial encounter - Adverse effect of other viral vaccines, sequela
  T50.Z15A - T50.Z15S Adverse effect of immunoglobulin, initial encounter - Adverse effect of immunoglobulin, sequela
  T50.Z95A - T50.Z95S Adverse effect of other vaccines and biological substances, initial encounter - Adverse effect of other vaccines and biological substances, sequela
  T50.905A - T50.905S Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter - Adverse effect of unspecified drugs, medicaments and biological substances, sequela
  T50.995A - T50.995S Adverse effect of other drugs, medicaments and biological substances, initial encounter - Adverse effect of other drugs, medicaments and biological substances, sequela
  T88.52XA - T88.52XS Failed moderate sedation during procedure, initial encounter - Failed moderate sedation during procedure, sequela
  Z01.810 Encounter for preprocedural cardiovascular examination
  Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
  Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
    Medical Necessity for Transthoracic  Echocardiography
 
  A18.84 Tuberculosis of heart
  A40.0 - A41.9 Sepsis due to streptococcus, group A - Sepsis, unspecified organism
  A42.7 Actinomycotic sepsis
  A52.01 Syphilitic aneurysm of aorta
  A52.02 Syphilitic aortitis
  A52.03 Syphilitic endocarditis
  A52.06 Other syphilitic heart involvement
  A54.83 Gonococcal heart infection
  A69.20 - A69.29 Lyme disease, unspecified - Other conditions associated with Lyme disease
  B33.21 - B33.23 Viral endocarditis - Viral pericarditis
  B37.6 Candidal endocarditis
  B39.4 Histoplasmosis capsulati, unspecified
  B39.5 Histoplasmosis duboisii
  B57.0 Acute Chagas' disease with heart involvement
  B57.2 Chagas' disease (chronic) with heart involvement
  B58.81 Toxoplasma myocarditis
  C38.0 Malignant neoplasm of heart
  C45.2 Mesothelioma of pericardium
  D15.1 Benign neoplasm of heart
  D86.0 - D86.9 Sarcoidosis of lung - Sarcoidosis, unspecified
  E03.5 Myxedema coma
  E08.51 - E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene - Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
  E09.51 - E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene - Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
  E10.51 - E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
  E11.51 - E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene - Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
  E13.51 - E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene - Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
  E83.10 - E83.19 Disorder of iron metabolism, unspecified - Other disorders of iron metabolism
  E85.1 - E86.9 Neuropathic heredofamilial amyloidosis - Volume depletion, unspecified
  G06.0 Intracranial abscess and granuloma
  G06.1 Intraspinal abscess and granuloma
  G45.0 - G45.3 Vertebro-basilar artery syndrome - Amaurosis fugax
  G45.8 Other transient cerebral ischemic attacks and related syndromes
  G45.9 Transient cerebral ischemic attack, unspecified
  G46.0 - G46.2 Middle cerebral artery syndrome - Posterior cerebral artery syndrome
  G47.30 Sleep apnea, unspecified
  H34.00 - H34.03 Transient retinal artery occlusion, unspecified eye - Transient retinal artery occlusion, bilateral
  I01.0 - I01.9 Acute rheumatic pericarditis - Acute rheumatic heart disease, unspecified
  I02.0 Rheumatic chorea with heart involvement
  I05.0 - I09.9 Rheumatic mitral stenosis - Rheumatic heart disease, unspecified
  I10 Essential (primary) hypertension
  I11.0 - I11.9 Hypertensive heart disease with heart failure - Hypertensive heart disease without heart failure
  I13.0 - I13.2 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease - Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
  I15.0 Renovascular hypertension
  I20.0 Unstable angina
  I20.1 - I24.9 Angina pectoris with documented spasm - Acute ischemic heart disease, unspecified
  I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
  I25.110 - I25.119 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
  I25.2 - I25.812 Old myocardial infarction - Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
  I25.84 - I27.9 Coronary atherosclerosis due to calcified coronary lesion - Pulmonary heart disease, unspecified
  I30.0 - I43 Acute nonspecific idiopathic pericarditis - Cardiomyopathy in diseases classified elsewhere
  I44.1 Atrioventricular block, second degree
  I44.2 Atrioventricular block, complete
  I44.7 Left bundle-branch block, unspecified
  I45.6 Pre-excitation syndrome
  I45.81 Long QT syndrome
  I45.9 Conduction disorder, unspecified
  I46.2 - I51.7 Cardiac arrest due to underlying cardiac condition - Cardiomegaly
  I51.9 Heart disease, unspecified
  I52 Other heart disorders in diseases classified elsewhere
  I63.30 - I63.6 Cerebral infarction due to thrombosis of unspecified cerebral artery - Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
  I63.89 - I63.9 Other cerebral infarction - Cerebral infarction, unspecified
  I66.01 - I66.9 Occlusion and stenosis of right middle cerebral artery - Occlusion and stenosis of unspecified cerebral artery
  I67.0 Dissection of cerebral arteries, nonruptured
  I67.841 - I67.848 Reversible cerebrovascular vasoconstriction syndrome - Other cerebrovascular vasospasm and vasoconstriction
  I67.850 - I67.858 Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy - Other hereditary cerebrovascular disease
  I67.89 Other cerebrovascular disease
  I70.0 Atherosclerosis of aorta
  I71.00 - I73.1 Dissection of unspecified site of aorta - Thromboangiitis obliterans [Buerger's disease]
  I73.81 - I73.9 Erythromelalgia - Peripheral vascular disease, unspecified
  I74.01 - I75.89 Saddle embolus of abdominal aorta - Atheroembolism of other site
  I77.70 - I77.79 Dissection of unspecified artery - Dissection of other specified artery
  I79.0 - I79.8 Aneurysm of aorta in diseases classified elsewhere - Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere
  I95.1 - I95.9 Orthostatic hypotension - Hypotension, unspecified
  I97.0 - I97.191 Postcardiotomy syndrome - Other postprocedural cardiac functional disturbances following other surgery
  I97.710 - I97.791 Intraoperative cardiac arrest during cardiac surgery - Other intraoperative cardiac functional disturbances during other surgery
  I97.88 - I97.89 Other intraoperative complications of the circulatory system, not elsewhere classified - Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
  J80 Acute respiratory distress syndrome
  J81.0 Acute pulmonary edema
  K68.11 Postprocedural retroperitoneal abscess
  M30.3 Mucocutaneous lymph node syndrome [Kawasaki]
  M31.4 Aortic arch syndrome [Takayasu]
  M32.0 - M32.9 Drug-induced systemic lupus erythematosus - Systemic lupus erythematosus, unspecified
  P22.8 Other respiratory distress of newborn
  P22.9 Respiratory distress of newborn, unspecified
  P28.3 Primary sleep apnea of newborn
  P28.4 Other apnea of newborn
  P28.89 Other specified respiratory conditions of newborn
  P29.0 Neonatal cardiac failure
  P29.11 - P29.12 Neonatal tachycardia - Neonatal bradycardia
  P29.2 Neonatal hypertension
  P29.4 Transient myocardial ischemia in newborn
  P29.89 - P29.9 Other cardiovascular disorders originating in the perinatal period - Cardiovascular disorder originating in the perinatal period, unspecified
  P84 Other problems with newborn
  P94.1 - P94.9 Congenital hypertonia - Disorder of muscle tone of newborn, unspecified
  P96.0 Congenital renal failure
  P96.3 - P96.5 Wide cranial sutures of newborn - Complication to newborn due to (fetal) intrauterine procedure
  P96.89 Other specified conditions originating in the perinatal period
  Q20.0 - Q25.29 Common arterial trunk - Other atresia of aorta
  Q26.2 Total anomalous pulmonary venous connection
  Q28.9 Congenital malformation of circulatory system, unspecified
  Q87.40 - Q87.43 Marfan's syndrome, unspecified - Marfan's syndrome with skeletal manifestation
  Q89.3 Situs inversus
  R00.1 - R01.2 Bradycardia, unspecified - Other cardiac sounds
  R06.00 Dyspnea, unspecified
  R06.02 - R06.09 Shortness of breath - Other forms of dyspnea
  R06.2 - R06.3 Wheezing - Periodic breathing
  R06.81 - R06.89 Apnea, not elsewhere classified - Other abnormalities of breathing
  R07.2 Precordial pain
  R07.82 - R07.9 Intercostal pain - Chest pain, unspecified
  R23.0 Cyanosis
  R40.20 - R40.2124 Unspecified coma - Coma scale, eyes open, to pain, 24 hours or more after hospital admission
  R40.2210 - R40.2224 Coma scale, best verbal response, none, unspecified time - Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission
  R40.2310 - R40.2324 Coma scale, best motor response, none, unspecified time - Coma scale, best motor response, extension, 24 hours or more after hospital admission
  R40.2340 - R40.2344 Coma scale, best motor response, flexion withdrawal, unspecified time - Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission
  R40.4 Transient alteration of awareness
  R47.01 Aphasia
  R50.2 - R50.82 Drug induced fever - Postprocedural fever
  R50.9 Fever, unspecified
  R55 Syncope and collapse
  R57.0 - R57.9 Cardiogenic shock - Shock, unspecified
  R60.0 - R60.9 Localized edema - Edema, unspecified
  R65.21 Severe sepsis with septic shock
  R78.81 Bacteremia
  R94.31 Abnormal electrocardiogram [ECG] [EKG]
  S21.309A - S21.309S Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, initial encounter - Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, sequela
  S22.5XXA - S22.5XXS Flail chest, initial encounter for closed fracture - Flail chest, sequela
  S25.00XA - S25.09XS Unspecified injury of thoracic aorta, initial encounter - Other specified injury of thoracic aorta, sequela
  S25.20XA - S25.29XS Unspecified injury of superior vena cava, initial encounter - Other specified injury of superior vena cava, sequela
  S25.401A - S25.499S Unspecified injury of right pulmonary blood vessels, initial encounter - Other specified injury of unspecified pulmonary blood vessels, sequela
  S26.01XA - S26.022S Contusion of heart with hemopericardium, initial encounter - Major laceration of heart with hemopericardium, sequela
  S26.11XA - S26.12XS Contusion of heart without hemopericardium, initial encounter - Laceration of heart without hemopericardium, sequela
  S26.90XA - S26.92XS Unspecified injury of heart, unspecified with or without hemopericardium, initial encounter - Laceration of heart, unspecified with or without hemopericardium, sequela
  T45.1X1A - T45.1X4S Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter - Poisoning by antineoplastic and immunosuppressive drugs, undetermined, sequela
  T50.905A - T50.905S Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter - Adverse effect of unspecified drugs, medicaments and biological substances, sequela
  T66.XXXA - T66.XXXS Radiation sickness, unspecified, initial encounter - Radiation sickness, unspecified, sequela
  T79.0XXA - T79.1XXS Air embolism (traumatic), initial encounter - Fat embolism (traumatic), sequela
  T79.4XXA - T79.4XXS Traumatic shock, initial encounter - Traumatic shock, sequela
  T80.211A - T80.29XS Bloodstream infection due to central venous catheter, initial encounter - Infection following other infusion, transfusion and therapeutic injection, sequela
  T81.10XA - T81.19XS Postprocedural shock unspecified, initial encounter - Other postprocedural shock, sequela
  T81.43XA - T81.44XS Infection following a procedure, organ and space surgical site, initial encounter - Sepsis following a procedure, sequela
  T82.01XA - T82.817S Breakdown (mechanical) of heart valve prosthesis, initial encounter - Embolism due to cardiac prosthetic devices, implants and grafts, sequela
  T82.827A - T82.827S Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter - Fibrosis due to cardiac prosthetic devices, implants and grafts, sequela
  T82.837A - T82.837S Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter - Hemorrhage due to cardiac prosthetic devices, implants and grafts, sequela
  T82.847A - T82.847S Pain due to cardiac prosthetic devices, implants and grafts, initial encounter - Pain due to cardiac prosthetic devices, implants and grafts, sequela
  T82.857A - T82.857S Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter - Stenosis of other cardiac prosthetic devices, implants and grafts, sequela
  T82.867A - T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter - Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela
  T82.897A - T82.897S Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter - Other specified complication of cardiac prosthetic devices, implants and grafts, sequela
  T82.9XXA - T82.9XXS Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter - Unspecified complication of cardiac and vascular prosthetic device, implant and graft, sequela
  T84.50XA - T84.59XS Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter - Infection and inflammatory reaction due to other internal joint prosthesis, sequela
  T85.79XA - T85.79XS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter - Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela
  T86.20 - T86.39 Unspecified complication of heart transplant - Other complications of heart-lung transplant
  Z01.818 Encounter for other preprocedural examination
  Z01.89 Encounter for other specified special examinations
  Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
  Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
  Z13.6 Encounter for screening for cardiovascular disorders
  Z48.21 Encounter for aftercare following heart transplant
  Z48.280 Encounter for aftercare following heart-lung transplant
  Z51.81 Encounter for therapeutic drug level monitoring
  Z94.1 Heart transplant status
  Z94.3 Heart and lungs transplant status
  Z95.2 Presence of prosthetic heart valve
  Z95.3 Presence of xenogenic heart valve
  Z95.4 Presence of other heart-valve replacement
    Medical Necessity for Transesophageal Echocardiography
  A18.84 Tuberculosis of heart
  C38.0 Malignant neoplasm of heart
  C45.2 Mesothelioma of pericardium
  D15.1 Benign neoplasm of heart
  E66.01 - E66.9 Morbid (severe) obesity due to excess calories - Obesity, unspecified
  I01.0 - I01.9 Acute rheumatic pericarditis - Acute rheumatic heart disease, unspecified
  I05.0 - I09.1 Rheumatic mitral stenosis - Rheumatic diseases of endocardium, valve unspecified
  I09.89 Other specified rheumatic heart diseases
  I20.0 Unstable angina
  I21.01 - I22.9 ST elevation (STEMI) myocardial infarction involving left main coronary artery - Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
  I23.1 Atrial septal defect as current complication following acute myocardial infarction
  I23.2 Ventricular septal defect as current complication following acute myocardial infarction
  I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction
  I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction
  I24.0 - I24.9 Acute coronary thrombosis not resulting in myocardial infarction - Acute ischemic heart disease, unspecified
  I25.10 - I25.119 Atherosclerotic heart disease of native coronary artery without angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
  I25.700 - I25.812 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris - Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
  I25.84 Coronary atherosclerosis due to calcified coronary lesion
  I26.01 - I26.99 Septic pulmonary embolism with acute cor pulmonale - Other pulmonary embolism without acute cor pulmonale
  I31.0 - I31.9 Chronic adhesive pericarditis - Disease of pericardium, unspecified
  I33.0 - I39 Acute and subacute infective endocarditis - Endocarditis and heart valve disorders in diseases classified elsewhere
  I42.0 - I42.9 Dilated cardiomyopathy - Cardiomyopathy, unspecified
  I43 Cardiomyopathy in diseases classified elsewhere
  I48.0 - I48.92 Paroxysmal atrial fibrillation - Unspecified atrial flutter
  I51.0 - I51.2 Cardiac septal defect, acquired - Rupture of papillary muscle, not elsewhere classified
  I63.40 - I63.49 Cerebral infarction due to embolism of unspecified cerebral artery - Cerebral infarction due to embolism of other cerebral artery
  I66.01 - I66.9 Occlusion and stenosis of right middle cerebral artery - Occlusion and stenosis of unspecified cerebral artery
  I71.00 - I71.03 Dissection of unspecified site of aorta - Dissection of thoracoabdominal aorta
  I74.01 - I74.9 Saddle embolus of abdominal aorta - Embolism and thrombosis of unspecified artery
  I82.220 - I82.221 Acute embolism and thrombosis of inferior vena cava - Chronic embolism and thrombosis of inferior vena cava
  I95.9 Hypotension, unspecified
  I97.0 Postcardiotomy syndrome
  J44.9 Chronic obstructive pulmonary disease, unspecified
  M32.11 Endocarditis in systemic lupus erythematosus
  M95.4 Acquired deformity of chest and rib
  M99.82 Other biomechanical lesions of thoracic region
  M99.88 Other biomechanical lesions of rib cage
  Q20.0 - Q25.29 Common arterial trunk - Other atresia of aorta
  Q25.5 - Q25.79 Atresia of pulmonary artery - Other congenital malformations of pulmonary artery
  Q67.6 - Q67.8 Pectus excavatum - Other congenital deformities of chest
  R57.0 - R57.9 Cardiogenic shock - Shock, unspecified
  R65.21 Severe sepsis with septic shock
  S21.309A - S21.309S Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, initial encounter - Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, sequela
  S26.00XA - S26.99XS Unspecified injury of heart with hemopericardium, initial encounter - Other injury of heart, unspecified with or without hemopericardium, sequela
  T80.0XXA - T80.0XXS Air embolism following infusion, transfusion and therapeutic injection, initial encounter - Air embolism following infusion, transfusion and therapeutic injection, sequela
  T81.718A - T81.718S Complication of other artery following a procedure, not elsewhere classified, initial encounter - Complication of other artery following a procedure, not elsewhere classified, sequela
  T81.72XA - T81.72XS Complication of vein following a procedure, not elsewhere classified, initial encounter - Complication of vein following a procedure, not elsewhere classified, sequela
  T82.01XA - T82.09XS Breakdown (mechanical) of heart valve prosthesis, initial encounter - Other mechanical complication of heart valve prosthesis, sequela
  T82.211A - T82.218S Breakdown (mechanical) of coronary artery bypass graft, initial encounter - Other mechanical complication of coronary artery bypass graft, sequela
  T82.6XXA - T82.817S Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter - Embolism due to cardiac prosthetic devices, implants and grafts, sequela
  T82.827A - T82.827S Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter - Fibrosis due to cardiac prosthetic devices, implants and grafts, sequela
  T82.837A - T82.837S Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter - Hemorrhage due to cardiac prosthetic devices, implants and grafts, sequela
  T82.847A - T82.847S Pain due to cardiac prosthetic devices, implants and grafts, initial encounter - Pain due to cardiac prosthetic devices, implants and grafts, sequela
  T82.857A - T82.857S Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter - Stenosis of other cardiac prosthetic devices, implants and grafts, sequela
  T82.867A - T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter - Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela
  T82.897A - T82.897S Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter - Other specified complication of cardiac prosthetic devices, implants and grafts, sequela
  T82.9XXA - T82.9XXS Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter - Unspecified complication of cardiac and vascular prosthetic device, implant and graft, sequela
  Z48.21* Encounter for aftercare following heart transplant
  Z48.280* Encounter for aftercare following heart-lung transplant
  Z94.1* Heart transplant status
  Z94.3* Heart and lungs transplant status
  Z95.2* Presence of prosthetic heart valve
  Z95.3* Presence of xenogenic heart valve
  Z95.4* Presence of other heart-valve replacement

Appplicable Modifiers

Some modifiers.

Policy History

Date Action Description
05/06/2019 Policy Changes New format, Added TEE and stress echo to the policy, added codes, added PICOs, Policy Guidlines changed, Policy title changec.
08/08/2017    
05/10/2016    
04/25/2012