CMS Pulmonary Stress Testing Form

Summary Of Evidence

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Analysis of Evidence

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Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed conditions. The pulmonary stress test will be considered medically necessary for these conditions:

INDICATIONS:

Evaluation of exercise tolerance

• Determination of functional impairment or capacity
• Determination of exercise-limiting factors and pathophysiologic mechanisms

Evaluation of undiagnosed exercise intolerance

• Assessing contribution of cardiac and pulmonary etiology in coexisting disease
• Symptoms disproportionate to resting pulmonary and cardiac tests
• Unexplained dyspnea when initial cardiopulmonary testing is nondiagnostic

Evaluation of patients with cardiovascular disease

• Functional evaluation and prognosis in patients with heart failure
• Selection for cardiac transplantation
• Exercise prescription and monitoring response to exercise training for cardiac rehabilitation (special circumstances; i.e., pacemakers)

Evaluation of patients with respiratory disease

• Functional impairment assessment (see specific clinical applications)
• Chronic obstructive pulmonary disease:
     - Establishing exercise limitation(s) and assessing other potential contributing factors, especially occult heart disease (ischemia)
     - Determination of magnitude of hypoxemia and for O2 prescription
     - When objective determination of therapeutic intervention is necessary and not adequately addressed by standard pulmonary function testing
• Interstitial lung diseases:
     - Detection of early (occult) gas exchange abnormalities
     - Overall assessment/monitoring of pulmonary gas exchange
     - Determination of magnitude of hypoxemia and for O2 prescription
     - Determination of potential exercise-limiting factors
     - Documentation of therapeutic response to potentially toxic therapy
• Pulmonary vascular disease (careful risk–benefit analysis required)
• Cystic fibrosis
• Exercise-induced bronchospasm

Specific clinical applications include:

1) Preoperative evaluation for:

• Surgery involving lung resection
• Elderly patients undergoing major abdominal surgery
• Lung volume reduction surgery for emphysema

2) Clinical decision making:

• Exercise evaluation and prescription for pulmonary rehabilitation
• Evaluation for impairment–disability
• Evaluation for lung, heart–lung transplantation

LIMITATIONS:

Absolute and relative contraindications to exercise testing (field walking tests) include:

Absolute Contraindications

• Acute myocardial infarction (3-5 days)
• Unstable angina
• Uncontrolled arrhythmias causing symptoms or hemodynamic compromise
• Syncope
• Active endocarditis
• Acute myocarditis or pericarditis
• Symptomatic severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolus or pulmonary infarction
• Thrombosis of lower extremities
• Suspected dissecting aneurysm
• Uncontrolled asthma
• Pulmonary edema
• SpO2 = 85% on room air
• Acute respiratory failure
• Acute non-cardiopulmonary disorder that may affect exercise performance or be aggravated by exercise (i.e., infection, renal failure, thyrotoxicosis)
• Mental impairment leading to inability to cooperate with the testing

Relative Contraindications

• Left main coronary artery stenosis or its equivalent
• Moderate stenotic valvular heart disease
• Severe untreated arterial hypertension at rest (200mmHg systolic, 120mmHg diastolic)
• Tachyarrythmias or bradyarrythmias
• High degree atrioventricular block
• Hypertrophic cardiomyopathy
• Significant pulmonary hypertension
• Advanced or complicated pregnancies
• Electrolyte abnormalities
• Orthopedic impairment that prevents walking