LCD L33577: Transthoracic Echocardiography (TTE)

Abstract:

Transthoracic Echocardiography is the ultrasonic examination of the heart through the chest wall. Two-dimensional (2D) TTE may allow visualization of the cardiac chambers, cyclic variation in myocardial wall thickness, valvular structure and function, the proximal great vessels and the pericardium.

Doppler flow evaluation uses the changes in frequency when a transmitted ultrasound wave is reflected from moving surfaces (e.g., heart valves, red blood cells) and allows measurement of blood flow velocity which can be used to identify valvular stenosis or regurgitation, estimate cardiac output and intracardiac pressures, or identify the presence of intracardiac shunts.

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 or portability of the instrument used to perform the study.

This policy addresses the medically necessary and appropriate application of TTE, including stress echocardiography. Transesophageal echocardiography (TEE) is the subject of a separate policy statement.

Indications:

Echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function. The general applications for coverage include:

Transthoracic Echocardiogram

INDICATIONS:

Ventricular Function, Cardiomyopathies and Heart Failure

• "When the etiology is in doubt, echocardiography can document or rule out the common cardiac causes of pulmonary congestion: left-sided valvular disease, depressed systolic or diastolic function, and cardiomyopathy. In this regard, echocardiography is the preferred initial diagnostic test when the history, physical examination, and routine laboratory tests suggest (or cannot eliminate) cardiac disease." (ACC/AHA/ASE 2003 Guideline Update, pg. 35)

• "Echocardiography is recommended for patients with edema with clinical signs of elevated central venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot be estimated with confidence and clinical suspicion of heart disease is high." TTE is also recommended for patients experiencing "dyspnea with clinical signs of heart disease."(ACC/AHA/ASE 2003 Guideline Update, pg. 37)

• "Echocardiography is not recommended in patients with edema when the jugular venous pressure does not appear to be elevated." (ACC/AHA/ASE 2003 Guideline Update, pg. 35).

Hypertensive Cardiovascular Disease

• Evaluating the cardiac effects of systemic hypertension (ACC/AHA/ASE 2003 Guideline Update, pg. 42)

• In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of left ventricular hypertrophy and /or left ventricular mass calculation.

Acute Myocardial Infarction and Coronary Insufficiency

• Evaluation of regional motion, systolic thickening perturbations and mural thinning

• Evaluation of right ventricular ischemia and/or infarction

• Diagnosis or evaluation of complications of acute infarction (e.g., mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture)

• Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. The medical record should document the medical necessity of the frequency for TTE assessment.

• "Evaluation of chest pain in patients with suspected acute myocardial ischemia, when baseline ECG and other laboratory markers are nondiagnostic and when study can be obtained during pain or within minutes after its abatement" is recommended in the ACC/AHA/ASE 2003 Guideline Update.

• Diagnosis of acute myocardial infarction when the clinical history and ECG findings are nondiagnostic. (ACC/AHA/ASE 2003 Guideline Update, pg. 15)

Exposure to Cardiotoxic Agents (chemotherapeutic and external)

An initial complete TTE may be performed prior to first administration of the agent with the frequency of repeat studies determined by the patient's clinical course and the toxicity profile of the agent being administered, although tests performed bimonthly during chemotherapy and at six (6) months following therapy are generally considered medically appropriate.

Cardiac Transplant and Rejection Monitoring

• TTE is an integral part of the cardiac donor-selection and donor-recipient matching process. Evaluation focuses on analysis of ventricular function and valvular integrity.

• TTE in the management of allograft recipients is typically performed weekly for the first four to eight (4-8) weeks following transplant, with reduced frequency over time. Absent acute rejection episodes, approximately two (2) TTE examinations are typically performed yearly in chronic transplant recipients. TTE of cardiac allografts is most appropriately serially performed at transplant centers by examiners with expertise in the management of cardiac allograft recipients. Uses in excess of the generally accepted frequency will be expected to have appropriate medical necessity documentation provided.

Native Valvular Heart Disease

• TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function.

• In some patients, Doppler echocardiography is the only noninvasive method capable of identifying the cause of a heart murmur. (ACC/AHA/ASE 2003 Guideline Update, pg. 7)

• Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, it is not medically necessary to repeat these examinations more frequently than annually. When the patient's clinical status shows evidence of change or the plan of care includes consideration for imminent valvular surgery, more frequent exams may be necessary.

Prosthetic Heart Valves (Mechanical & Bio-prostheses)

TTE assessment after prosthetic valve implant to establish a baseline structural and hemodynamic profile with reassessment following convalescence (3-6 months). Thereafter, re-evaluation of patients with suspected dysfunction, thrombosis or a change in clinical status or symptoms is indicated.

Acute Endocarditis

• Diagnostic and evaluation of suspected endocarditis or complications or sequelae of acute infective endocarditis.

• Examination frequency in the acute phase of illness is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be determined by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves.

Pericardial Disease

• Detection and quantitation of the amount of pericardial effusion.

• To characterize the hemodynamic consequences of pericardial fluid accumulation.

• As an adjunct during the removal of pericardial fluid and creation of pericardial windows.

• Diagnosis of pericardial constriction and differentiating it from restrictive myocardial disease (may require Doppler).

• The acute clinical status will dictate examination frequency. In a patient with evolving pericardial pathology, a limited focused TTE exam may be appropriate.

Abnormalities of the Great Vessels

• Evaluation of acute or chronic aortic pathology (Note: TEE is often a more determinative study unless images suitable for serial quantitation can be obtained by TTE).

• Routine (yearly) evaluation is indicated in patients with severe aortic stenosis or regurgitation, in whom the information obtained will be used in determining or modifying the plan of care.

• With ascending aortic dilatation or aneurysms, a focused limited follow-up exam to serially measure ascending aortic diameters may be indicated.

• Evaluation of the main pulmonary artery segment and the proximal right and left pulmonary arteries.

• Evaluation of the vena cavae and diagnosing congenital and acquired abnormalities such as vena caval thrombosis, vena caval dilation, and thrombosis or extension of tumors from the inferior vena cava to the right-heart chambers.

Congenital Heart Disease

• TTE with Doppler hemodynamic measurements for diagnosis and noninvasive serial assessment of most congenital heart diseases.

• When the disease process and therapy are stable, assessment more often than annually requires medical necessity documentation.

• In asymptomatic patients following repair of ASD, PFO, VSD or PDA follow up examination is only indicated within the first year after correction.

Suspected Cardiac Thrombi and Embolic Sources

TTE is indicated for the evaluation for cardiovascular source of embolic events (PFO/ASD, atrial or ventricular thrombus, intracardiac tumor) in evaluation for patients with abrupt occlusion of a major peripheral or visceral artery or for with neurological events without evidence of cerebrovascular disease or other obvious cause.

Cardiac Tumors and Masses

• Diagnosis and assessment of cardiac tumors.

• Serial TTEs may be medically necessary to monitor tumor size or tumor recurrence.

Critically Ill and Trauma Patients

• Diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion, or pericardial effusion.

• Assessment of volume status.

• The frequency of these typically acute studies will be dictated by the clinical circumstances.

Arrhythmias and Palpitations

• Transthoracic echocardiography is useful in defining cardiac function in which arrhythmias occur, and may be useful in the management of cardiac arrhythmias. Some arrhythmias are frequently associated with underlying organic heart disease or may predispose the patient to hemodynamic deterioration. Atrial fibrillation and atrial flutter are examples of arrhythmias in which echocardiography may be appropriate to assess the underlying disorder. Echocardiographic studies are appropriate only when there is evidence of heart disease.

• Palpitations without evidence of arrhythmias, or minor arrhythmias (e.g., isolated APC's or VPC's) without evidence of heart disease, are not covered indications for transthoracic echocardiography.

Syncope

In the initial evaluation of syncope and when other findings are suggestive of valvular heart disease or obstructive cardiomyopathy.

Pulmonary

To assess right ventricular size and performance, and quantify the severity of pulmonary hypertension using Doppler flow in unexplained pulmonary hypertension, and pulmonary emboli with suspected right atrial or right ventricular sources of emboli.

Contrast Echocardiography

Contrast echocardiography is indicated when a conventional study has failed to provide adequate and critically needed information on left ventricular function. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient. Contrast is indicated when more than two (2) contiguous segments of the left ventricular border are not visualized.

LIMITATIONS:

1. Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor as having a positive family history, e.g., familial history of Marfan's disease). A screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition.

The following indications (#2-15) are deemed to be not medically necessary and are therefore not reimbursable:

2. Routine (yearly) evaluation of asymptomatic patients with corrected ASD, VSD or PDA more than one year after successful correction.

3. Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no change in clinical status.

4. Routine (yearly) re-evaluation of an asymptomatic patient with mild native aortic stenosis or mild-moderate native mitral stenosis and no change in clinical status.

5. Routine (yearly) re-evaluation of native valvular regurgitation in an asymptomatic patient with mild regurgitation, no change in clinical status and normal left ventricular size.

6. Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status.

7. Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status.

8. Routine (yearly) evaluation of hypertrophic cardiomyopathy in a patient with no change in clinical status.

9. Patients who have isolated APC or VPC without other evidence of heart disease.

10. Evaluation of LV function with prior ventricular function within the past year with normal (such as prior echocardiogram, left ventriculogram, SPECT, cardiac MRI) in patients in whom there has been no change in clinical status.

11. Initial evaluation of patient with suspected pulmonary embolism in order to establish diagnosis.

12. Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of bacteremia or new murmur.

13. Re-evaluation of a patient with known hypertensive heart disease without a change in clinical status.

14. Routine evaluation of patients with systemic hypertension without suspected hypertensive heart disease.

15. Evaluation of a patient with atrial fibrillation/flutter for left atrial thrombus or spontaneous contrast when a decision has been made to anticoagulate and not to perform cardioversion.

[Items 2-15, see ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography, JACC 2007].

Follow-up Studies or Limited Studies

N/A