CMS Local Coverage Determination (LCD)

CMS Transesophageal Echocardiogram Form

Effective Date

10/01/2019

Last Reviewed

10/02/2019

Original Document

  Reference



Background for this Policy

Summary Of Evidence

N/A

Analysis of Evidence

N/A

History/Background and/or General Information

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.

Covered Indications

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

  • Examination of prosthetic heart valves, primarily mitral
  • Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions. TEE may complement transthoracic echocardiography particularly to assess for left atrial thrombus.
  • 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
  • Intra-operative guide to left ventricular function
  • Inadequacy of transthoracic echo due to:
    • chest wall deformity, COPD
    • open heart or chest surgery
    • chest trauma
    • obesity

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.