Humana Commercial Clinical Policy

Humana Tilt Table Testing Form


Effective Date

06/22/2023

Last Reviewed

NA

Original Document

  Reference



Description

Tilt table or upright tilt table testing is a diagnostic test used for evaluation of susceptibility to neurocardiogenic syncope (also known as neurally mediated or vasovagal syncope) when the initial evaluation is insufficient to establish a diagnosis. The initial evaluation includes, but may not be limited to, obtaining a complete history and physical and conducting a 12-lead electrocardiogram (ECG) to rule out cardiac dysfunction or symptomatic arrhythmia of immediate concern.

During testing, an individual is supported by safety straps, a foot plate and lies upon a special tilt table while continuous ECG and noninvasive blood pressure monitoring are performed throughout the procedure. Beginning with a pretilt or supine stabilization phase in a quiet environment for approximately 20 minutes, the individual is then repositioned to an angle ranging from 60 to 80 degrees for a period of 20 to 45 minutes while heart rate and symptoms are recorded. If the initial test is negative or the individual remains asymptomatic during upright tilting, a pharmacologic provocative agent (e.g., isoproterenol or nitroglycerin) may be used during repeat testing. A positive test is one that reproduces symptoms of syncope.

A tilt table test may be helpful for the evaluation of postural orthostatic tachycardia syndrome (POTS) when orthostatic vital signs are normal and the clinical suspicion of POTS is high.

A tilt table may be used in a 5 minute passive tilt in conjunction with beat-to-beat blood pressure monitoring for certain types of autonomic nerve function testing. For information regarding autonomic nerve function testing, please refer to Autonomic Nerve Function Testing Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for tilt table testing alone or in conjunction with administration of provocative agents for the following indications:

  • Differentiating convulsive syncope from epilepsy for an individual with recurrent unexplained seizure-like episodes, unresponsive to antiseizure medication; OR
  • Establish diagnosis of pseudosyncope for an individual with daily symptoms (e.g., blurred vision, cold clammy skin, feeling warm, lightheadedness, nausea, pale skin, tunnel vision); OR
  • Recurrent syncopal episodes; OR
  • Single syncopal episode in an excessively high-risk individual (e.g., mission critical or occupational hazard such as commercial driver, roofer, surgeon); AND all of the following:
  • Documentation of inconclusive initial complete history and physical exam; AND
  • 12-lead ECG testing performed within the preceding 90 days that is negative for symptomatic arrhythmia of immediate concern; AND

Tilt Table Testing Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0547-008
Page: 3 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • No evidence of structural cardiovascular disease or in the presence of structural heart disease after cardiac causes of syncope have been excluded by appropriate testing (e.g., echocardiogram, exercise testing)

Humana members may be eligible under the Plan for tilt table testing alone or in conjunction with administration of provocative agents for POTS for the following indications:

  • Documentation of inconclusive initial complete history and physical exam; AND
  • 12-lead ECG testing performed within the preceding 90 days that is negative for symptomatic arrhythmia of immediate concern

Coverage Limitations

Humana members may NOT be eligible under the Plan for tilt table testing for any indications other than those listed above including, but may not be limited to, the following:

  • Chronic fatigue syndrome; OR
  • Evaluation of recurrent unexplained falls; OR
  • Evaluation of therapy/treatment for syncope; OR
  • Evaluation of unexplained syncope in the presence of neuropathies or dysautonomias that may contribute to systemic hypotension; OR
  • Recurrent dizziness and vertigo (for information regarding coverage determination/limitations, please refer to Chronic Vertigo Evaluation and Treatment Medical Coverage Policy); OR
  • Single syncopal episode without injury and not in a high risk setting (e.g., mission critical or occupational hazard such as commercial driver, roofer, surgeon) with clinical symptoms supportive of neurocardiogenic syncope

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in Tilt Table Testing Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0547-008
Page: 4 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Additional information about neurocardiogenic or vasovagal syncope may be found from the following websites:
Background
  • American Heart Association
  • National Library of Medicine
Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Tilt Table Testing Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0547-008
Page: 5 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

  1. American Academy of Neurology (AAN). Model Coverage Policy. Autonomic testing. https://www.aan.com. Published October 2014. Accessed June 16, 2023.
  2. American Heart Association (AHA). 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope. https://www.heart.org. Published 2017. Accessed June 16, 2023.
  3. ClinicalKey. Calkins HG, Zipes DP. Hypotension and syncope. In: Libby P, Bonow RO, Mann D, Tomaselli MD, Bhatt D, Solomon MD. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:1387- 1397. https://www.clinicalkey.com. Accessed June 16, 2023.
  4. ClinicalKey. Chemlimsky T, Chemlimsky G. Disorders of the autonomic nervous system. In: Jankovic J, Mazziotta JC, Pomeroy SL, Newman N. Bradley and Daroff's Neurology in Clinical Practice, 2-Volume Set. 8th ed. Elsevier; 2021:1930-1957. https://www.clinicalkey.com. Accessed June 16, 2023.
  5. Hayes, Inc. Medical Technology Directory (ARCHIVED). Autonomic nervous system monitoring for neuropathy. https://evidence.hayesinc.com. Published January 29, 2010. Updated February 4, 2014. Accessed June 16, 2023.
  6. Heart Rhythm Society (HRS). 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. https://www.hrsonline.org. Published May 13, 2015. Updated November 18, 2020. Accessed June 16, 2023.
  7. MCG Health. Tilt table testing. 26th edition. https://www.mcg.com. Accessed May 2, 2023.
  8. Thijs, R, Brignole, M, Falup-Pecurariu, C, Fanciulli, A, et al. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness: Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Clin Auton Res. 2021;31:369–384.
  9. UpToDate, Inc. Approach to the adult patient with fatigue. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  10. UpToDate, Inc. Clinical features and diagnosis of myalgic encephalomyelitis/ chronic fatigue syndrome. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  11. UpToDate, Inc. Mechanisms, causes, and evaluation of orthostatic hypotension. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  12. UpToDate, Inc. Postural tachycardia syndrome. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  13. UpToDate, Inc. Reflex syncope in adults and adolescents: clinical presentation and diagnostic evaluation. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  14. UpToDate, Inc. Reflex syncope in adults and adolescents: treatment. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
  15. UpToDate, Inc. Syncope in adults: risk assessment and additional diagnostic evaluation. https://www.uptodate.com.

Tilt Table Testing Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0547-008
Page: 6 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. UpToDate, Inc. Upright tilt table testing in the evaluation of syncope. https://www.uptodate.com. Updated May 2023. Accessed June 16, 2023.
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