Humana Transesophageal and Transthoracic Echocardiogram - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

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ID Number

Jurisdiction Medicare Administrative Contractors (MACs)

Applicable States/Territories

• NCD: Ultrasound Diagnostic Procedures 220.5
• LCD LCA: Transthoracic Echocardiography (TTE) Transesophageal Echocardiography (TEE) - L33577 A56781 133579 A52868 - J6, JK - National Government Services, Inc. (Part A/B MAC) - CT, IL, MA, ME, MN, NH, NY, VT, WI
• LCD LCA: Transesophageal Echocardiography (TEE) - L35016 A56505 - JH, JL - Novitas Solutions, Inc. (Part A/B MAC) - AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX
• LCD LCA: Transthoracic Echocardiography (TTE) Transesophageal Echocardiography (TEE) - L34338 AS57306 134337 A56809 - J15- CGS Administrators, LLC (Part A/B MAC) - KY, OH
• LCD LCA: Echocardiography for Myocardial Perfusion - L37379 A56625 138786 A58503 - JJ, JM - Palmetto GBA (Part A/B MAC) - AL, GA, NC, SC, TN, VA, WY
• LCD LCA: Transesophageal Echocardiogram - JN - First Coast Service Options, Inc. (Part A/B MAC) - FL, PR, US. VI

Description

Transesophageal echocardiography (TEE) is an ultrasound method that uses a transducer inserted into the esophagus to allow different views of the heart than transthoracic echocardiography (TTE). TEE provides a close and detailed visualization of the heart and its surroundings and provides clearer images than standard echocardiography due to the proximity of the esophagus to the heart. This enables a more precise assessment of cardiac function, valves and other cardiac structures. 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.

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TEE is often conducted when TTE is not sufficiently technically effective. TEE is the preferred choice over TTE for a variety of indications and is appropriate when there is a reasonable expectation that the procedure can offer information unavailable through TTE or other less invasive imaging methods, significantly aiding in treatment decisions.

Transthoracic echocardiography (TTE) is a noninvasive procedure that utilizes ultrasound to produce detailed images of the heart’s structure and function. It involves sending sound waves through the chest wall to assess the heart, detect any issues and evaluate blood flow within the organ.

Doppler flow evaluation in TTE utilizes Doppler ultrasound to assess blood circulation within the heart and blood vessels. This involves analyzing the frequency shift of reflected soundwaves from mobile structures (such as heart valves and red blood cells), providing details about the direction, velocity and characteristics of blood flow. This analysis aids in evaluating heart valve function, identifying irregularities and assessing overall cardiovascular performance during TTE.

This procedure is valuable for pinpointing valvular stenosis or regurgitation, estimating cardiac output and intracardiac pressures or identifying the presence of intracardiac shunts.

To qualify as a valid echocardiographic service, both TTE and TEE must be conducted by a qualified health care professional for an approved clinical indication. It should include a permanent record of the findings, sufficient data to support conclusions and an appropriate interpretation along with a written report. These standards hold regardless of the size or portability of the instrument used to perform the study.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

Please refer to the above CMS guidance for transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE).

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines.

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage

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