Summary Of Evidence

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Analysis of Evidence

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Abstract:

Transesophageal echocardiography (TEE) is ultrasonic examination of the heart performed by placing the transducer in the esophagus which allows different views of the heart than transthoracic echocardiography (TTE). TEE is particularly useful for posterior structures, such as the pulmonary veins, left atrium, and mitral valve and provides better visualization of the aortic root, valve and the ascending and descending aorta and arch.

TEE is frequently performed because TTE was not technically adequate. In addition, there are a number of medical conditions for which TEE is preferred over transthoracic echocardiography (see indications below). TEE is considered medically necessary when there is a reasonable expectation that it will both provide information not available with TTE or other less invasive forms of imaging and significantly contribute to management decisions regarding treatment of the patient.

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.

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

Indications:

Mitral valve disease:
TEE is indicated for the following:

1. When needed to assess the etiology of mitral regurgitation
2. When needed to assist in the decision making: mitral valve repair vs. replacement
    

Endocarditis:
TEE is indicated for the following:

1. When the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology) and TTE does not document endocarditis. TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae).
2. Re-evaluation in complex endocarditis;
3. Evaluation of bacteremia without known source;
4. Evaluation of suspected or actual prosthetic valve endocarditis otherwise obscured because of reverberations and other image artifacts related to mechanical or other non-native valves during TTE.

Valvular Prostheses (mechanical and bioprostheses): TEE is indicated in the evaluation of suspected prosthetic valve dysfunction when therapeutic decisions are critical and TTE is inconclusive and/or when the left atrium must be well-visualized. TEE is not routinely indicated in all patients with prosthetic valves.

Suspected Cardiac Thrombi and Emboli:
TEE is indicated for the following:

1. Evaluation of the left atrium and atrial appendage for clot, when clot is not visualized on TTE;
2. Evaluation for an ASD, patent foramen ovale or atrial septal aneurysm with clot; and
3. Evaluation of the mitral valve in patients with a history of emboli.

Cardiac/Pericardial Masses and Other Pericardial Disease:
TTE and TEE have comparable sensitivity in the assessment of right heart masses. Therefore, TEE is indicated for the following:

1. Visualization of left atrial masses when needed to provide therapeutic direction (cystic vs. solid, attachment, infiltration);
2. When cardiac mass lesions (including tumors on cardiac valves) are suspect and cannot be visualized on TTE, and TEE is needed for development of a management strategy;
3. To assess pericardial effusion when surface studies do not provide adequate information. "The risk of pericardiocentesis may be reduced by the use of echocardiographic guidance and monitoring of needle aspiration, particularly for loculated or small effusions." (ACC/AHA/ASE 2003 Guideline Update, pg. 39).

Aortic Pathological Conditions and Diseases of the Great Vessels:

1. TEE may be indicated when adequate visualization of the aortic root is not sufficient with TTE.
2. TEE may be indicated for identification of aortic dissection, aortic ulceration, atherosclerotic plaque, and mural thrombotic material.
3. TEE has a particularly high degree of sensitivity and specificity for aortic dissection. TEE is the technique that is indicated in examination of the entire aorta, especially in emergency situations.
4. Because descending thoracic aortic aneurysms are difficult to visualize using TTE, TEE is recommended for this condition.
5. Visualization of the superior vena cava and diagnosing various congenital and acquired abnormalities, such as vena caval thrombosis;
6. Visualization of the proximal inferior vena cava, vena caval dilation and detection of thrombosis or extension of tumors from the inferior vena cava to the right-heart chambers;
7. Visualization of all four pulmonary veins;
8. Evaluation of the heart and great vessels following blunt trauma to the chest (e.g., rupture or transsection of the aorta, acute dissection, hematoma, etc.)
9. When needed to assist in the decision making prior to aortic valve operative intervention.

Congenital Heart Disease:
TEE is indicated for the following:

1. Patients with congenital heart disease postoperatively where fibrosis, echo opaque patches and prostheses, inadequate penetration, and acoustical shadowing can result in incomplete TTE data;
2. Patients in which TTE is technically inadequate or anatomic definition is incomplete;
3. Patients in whom a more precise definition of atrial, outflow tract and proximal pulmonary vascular anomalies by TEE can be critical to management strategies;
4. To assess complications of congenital heart surgery, visualization of shunt flow across atrial-septal defects, guidance of clamshell device to close atrial-septal defects, diagnosis of cor triatriatum, and detection of pulmonary valve abnormalities.

Critically Ill Patients:
TEE is indicated for the following:

1. Management of the critically ill patient when TTE is otherwise contraindicated (e.g., chest or other major trauma) or inadequate (e.g., patient on a ventilator or with COPD, or in postoperative patients who are unable to be positioned for TTE);
2. Patients with persistent hypoxemia having suspected right-to-left shunt;
3. Patients with complications of myocardial infarction (ruptured septum, papillary muscle, or free wall);
4. Hemodynamically unstable patients in whom TTE images are suboptimal;
5. Evaluation of brain-dead patients being considered as cardiac donors;
6. Persistent unexplained fever when endocarditis or myocardial abscess is suspected and TTE is non-diagnostic.

Interventional and Surgical TEE:
TEE is indicated for the following:

1. Guidance during percutaneous cardiac interventions such as during the creation of shunts, placement of septation devices, valvuloplasty procedures, endomyocardial biopsy, electrophysiologic studies/procedures, placement of septal or atrial appendage occluders or during percutaneous valve replacement;
2. Intraoperative evaluation to assess prosthetic or repaired/reconstructed valve function, or the integrity/function of complex congenital heart repairs;
3. Intraoperative evaluation to assess the integrity of the cardiopulmonary circulation in patients during lung or heart-lung transplants; and
4. Intraoperative assessment for presence and/or severity of outflow tract obstruction or presence/repair of an intracardiac shunt;
5. Intraoperative assessment of wall motion abnormalities in the case of acute deterioration in the patient's status, once the chest has been closed;
6. Only TEE done for specific diagnostic purposes may be separately payable during intraoperative use (TEE used for monitoring purposes is not separately payable). The results of the test must be used in making management decisions on the patient's intraoperative treatment. A covered service must include a complete interpretation/report by the performing physician, and must be available if requested.

Doppler Color Flow Velocity Mapping:

1. Spectral Doppler echocardiography and Doppler color flow-velocity mapping may be necessary in addition to an echocardiogram when the examination could contribute significant information to the patient's condition or treatment plan. Typically, Doppler is indicated in the evaluation of some heart murmurs, valvular problems, shunts, suspected congenital heart disease, complications of myocardial infarction, or cardiomyopathy. Doppler should be medically necessary for the evaluation and management of the patient.
2. "Color/spectral Doppler may not be useful or appropriate in certain relatively small and well-defined patient populations when there is a recent comprehensive examination and the test is being ordered for re-evaluation of a limited problem." (ASE comment).
3. The use of the Doppler is inherent in the ultrasonic cardiac evaluation. However, if the test reports fail to document the use of this technique to assess these structures and function (e.g., measurement of valvular insufficiency or stenosis, myocardial diastolic function, etc. as described by the ASE), or if the medical records fail to document that the examination was "clinically necessary" (e.g., follow-up of pericardial effusion size) then the Doppler portion of the test may be considered medically unnecessary and denied.
   
   

3-Dimensional Echocardiography
When billed with TEE, it is indicated for:

1. The pre-operative planning of valve repair for multiple etiologies of mitral regurgitation;
2. Assessment of mitral stenosis and in the accurate calculation of mitral valve area;
3. Pre-operative planning for diagnosis and treatment of atrial septal defects;
4. Pre-operative and intraoperative planning for interventional cardiac procedures (e.g., transcatheter placement of occluders for atrial septal defects or patent foramen ovales, or paravalvular dehiscence or leaks;
5. Intraoperative mapping for atrial ablation procedures.
6. The evaluation of tricuspid valve disease.

While three-dimensional echocardiography may provide improved calculation of volume when compared to 2D echocardiography, its value in affecting clinical outcomes is not yet proven and it is therefore not medically necessary.

TEE is indicated for cardioversion in patients:

1. Requiring urgent (not emergent) cardioversion for whom extended pre-cardioversion anticoagulation is not desirable;
2. Who have had prior cardioembolic events thought to be related to intra-atrial thrombus;
3. For whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results;
4. For whom intra-atrial thrombus has been demonstrated in previous TEE. (ACC/AHA/ASE 2003 Guideline Update, pgs. 49-50)

Limitations:

Screening examinations to identify structural cardiac abnormalities in the absence of established diagnoses, signs or symptoms, are not considered reasonable and necessary.

TEE does not provide incremental information over that obtained by TTE in the serial assessment and management of pericardial pathology. Therefore, it will not be covered, unless there are loculated posterior effusions or adequate visualization of the pericardium is not possible by TTE.

In general, TTE provides accurate and serial noninvasive assessment of global and regional left ventricular function. Unless TTE is technically inadequate and clinical data is insufficient for a management decision, TEE will not be covered. Transthoracic echocardiographic assessment of left ventricular function is considered preferable to TEE in all other circumstances.

Intraoperative TEE is reimbursable to a cardiologist or other physician who is not part of the surgical/anesthesia team but only when performed as a diagnostic test and not for monitoring purposes (TEE for intraoperative monitoring is included in the anesthesia care).

In aortic root dilation in Marfan Syndrome or other connective tissue syndromes, the ACC AHA/ASE 2003 Guideline Update recommends TTE over TEE as the first choice for examination. "TEE should only be used if the examination is incomplete or additional information is needed." (pg. 42.)

In most patients with valvular prostheses TTE provides diagnostic functional information and noninvasive serial follow-up. However, in some patients, acoustical shadowing can decrease data acquisition. If TTE provides adequate information for diagnosis and management, then TEE is not covered. The medical record should document any need for additional information.

In general, TTE can reliably diagnose or exclude evidence of potentially embolic material located in a ventricle. The TEE may complement TTE, particularly to assess for left atrial thrombus and patent foramen ovale or atrial septal aneurysm. The additional information that can be provided by TEE should be reasonably anticipated to be of therapeutic relevance before the patient is subjected to TEE, otherwise the TEE is not covered.

Training Requirements:

Medicare expects a satisfactory level of competence from providers who submit claims for services rendered for these services to be considered medically necessary. Tests performed by providers not meeting these levels of competence will be denied.

The acceptable levels of competence are outlined as follows:
a. 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 technical portion of 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. Any non-physician personnel used by an IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. (42 CFR, Section 410.33c)
4. b. 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 Perioperative Transesophageal Echocardiography (National Board of Echocardiography); or
   2. The physician has Level II training in transesophageal echocardiography (including documentation of the performance of 25 esophageal intubations and 50 supervised interpretations), 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 has been credentialed for this procedure by the hospital where the physician performs this service.
   3. The submission of claims for transesophageal 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.
      
      The requirements have been in effect in New York and Connecticut since prior to 2011 and are effective in Illinois (for Part B providers), Maine, Massachusetts, Minnesota, New Hampshire, Rhode Island, Vermont and Wisconsin (for Part B providers) as of January 1, 2017.