Clinical Medical Policy Department Clinical Affairs Division

Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) [For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr. Go to “Comunicados a Proveedores”, and click “Cartas Circulares”.]

Medical Policy: MP-ME-03-10 Original Effective Date: March 18, 2010 Revised: February 9, 2021 Next Revision: February, 2022

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION

Cardiac output is a functional measure defined as the amount of blood the pumps through the in a minute. The amount of blood put out by the left of the heart in one contraction is called the . The stroke volume and the determine the cardiac output. A normal adult has a cardiac output of 4.7 liters (5 quarts) of blood per minute (MedicinetNet, 2018).

The gold standard for measuring cardiac output is use of a thermo-dilution catheter; however, this is an invasive technique that poses a risk to the patient. Thermodilution is an indicator-dilution method of measuring blood flow. This method is based on the premise that when an indicator substance is added to circulating blood, the rate of blood flow is inversely proportional to the change in concentration of the indicator over time. The indicator substance can be a dye (dye-dilution method) or a fluid with a different temperature than blood (thermodilution method). A dextrose or saline solution that is colder than blood is injected through the proximal port of the catheter in the right . The cold fluid mixes with blood in the right heart chambers, and the cooled blood is ejected into the and flows past the thermistor on the distal end of the catheter. The thermistor records the change in blood temperature with time and sends this information to an electronic instrument that record and displays a temperature-time curve. The area under this curve is inversely proportional to the rate of blood flow in the pulmonary artery. In the absence of intracardiac shunts, this flow rate is equivalent to the (average) cardiac output. (Russell, 2008)

Impedance cardiography (ICG), also referred to by the broader term, Thoracic Electrical Bioimpedance (TEB), is a noninvasive means of measuring cardiac output and other functional parameters. A small electric current is applied to the chest through electrodes placed on the neck and sides of the chest. Resistance to the current (impedance) is measured through sensors also placed on the neck and sides of the chest. The pulsatile flow of blood causes fluctuations in the current, and the device calculates cardiac output from the impedance waveform. ICG is used in the management of several heart-related conditions, including CHF, pacemaker calibration, and heart transplant.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 1 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 1 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits, and coverage.

INDICATIONS

I. Medical Card System, Inc., (MCS) will consider medically necessary the use of Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) under the following indications:

1. Differentiation of cardiogenic from pulmonary causes of acute dyspnea when:

 Medical history, physical examination, and standard assessment tools provide insufficient information; and

 The treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.

2. Optimization of atrioventricular (A/V) interval for patients with A/V sequential cardiac pacemakers when:

 Medical history, physical examination and standard assessment tools provide insufficient information; and

 The treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.

3. Monitoring of continuous inotropic therapy for patients with terminal congestive heart failure, when those patients have chosen to die with comfort at home, or for patients waiting at home for a heart transplant.

4. Evaluation for rejection in patients with a heart transplant as a predetermined alternative to a myocardial biopsy. Medical necessity must be documented should a biopsy be performed after TEB.

5. Optimization of fluid management in patients with congestive heart failure when:

 Medical history, physical examination, and standard assessment tools provide insufficient information; and

 The treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 2 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 2 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division 6. Management of drug-resistant hypertension. Drug resistant hypertension is defined as failure to achieve goal blood pressure (BP) in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.

II. The following are examples of appropriate clinical indications for which MCS will consider the assessment of Cardiac Output by Electrical Bioimpedance medically necessary:

1. For patients with structural heart disease (with an ejection fraction £ 40%) associated with the development of congestive heart failure (e.g., valvular and congenital, post myocardial infarction, rheumatic heart disease).

2. For patients with inflammatory heart disease (with an ejection fraction £ 40%) associated with the development of congestive heart failure (e.g., myocarditis and cardiomyopathy, pericarditis and constrictive pericardial scarring, rheumatic heart disease).

3. For patients with ischemic heart disease (with an ejection fraction £ 40%) associated with the development of congestive heart failure (e.g., post myocardial infarction, ischemic cardiomyopathy, ischemic mitral valve or left ventricular dysfunction).

4. For patients with cardiac disease resulting in congestive heart failure (CHF) with normal left ventricular function (e.g., diastolic dysfunction, restrictive cardiomyopathy/infiltrative such as amyloidosis or cancer of the heart).

5. For patients with pulmonary disease associated with congestive heart failure (e.g., cor - pulmonale and the need to distinguish between pulmonary and cardiac disease as the cause, pulmonary hypertension).

6. For acute conditions for which the patient might present to an outpatient setting and in which a decision regarding intervention is necessary (e.g., pericardial effusion with possible tamponade, myocardial infarction, cardiac trauma).

7. For patients with recent pacemaker implants who demonstrate clinical manifestations of unexplained fatigue, symptomatic hypotension, or congestive heart failure.

8. For the titration of therapeutic agents in the setting of symptomatic congestive heart failure.

9. For acute heart rejection during outpatient follow-up of heart transplant patients (as a supplement to invasive ); and/or

10. For patients with acute/chronic renal failure or end stage renal disease/dialysis who demonstrate clinical manifestations of unexplained shortness of breath, unexplained reduced access flow, and symptomatic hypotension/hypertension.

LIMITATIONS

1. Cardiac output by Electrical Bioimpedance is NOT COVERED for the following indications:

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 3 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 3 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division a. Monitoring of patients with proven or suspected disease involving severe regurgitation of the .

b. Patients with minute ventilation (MV) sensor function pacemakers (since the device may adversely affect the functioning of that type of pacemaker).

c. During cardiac bypass surgery and/or

d. In the management of all other forms of hypertension (with the exception of drug- resistant hypertension as outlined below, and Indication #6 from Part 1):

o Drug resistant hypertension is defined as failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic (CMS NCD 20.16, 2007).

e. All other uses of TEB not otherwise specified (CMS NCD 20.16, 2007).

CODING INFORMATION CPT® Codes (List may not be all inclusive) CPT® Codes DESCRIPTION 93701 Bioimpedance-derived physiologic cardiovascular analysis Current Procedural Terminology (CPT®) 2020 American Medical Association: Chicago, IL.

ICD-10 Codes (List may not be all inclusive) ICD-10-Codes DESCRIPTION A18.84 Tuberculosis of heart I09.81 Rheumatic heart failure I10 Essential (primary) hypertension I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I15.0 Renovascular hypertension I15.1 Hypertension secondary to other renal disorders I15.2 Hypertension secondary to endocrine disorders

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 4 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 4 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division I15.8 Other secondary hypertension I15.9 Secondary hypertension, unspecified I16.0 Hypertensive urgency I16.1 Hypertensive emergency I16.9 Hypertensive crisis, unspecified I27.0 Primary pulmonary hypertension I27.1 Kyphoscoliotic heart disease I27.20 Pulmonary hypertension, unspecified I27.21 Secondary pulmonary arterial hypertension I27.22 Pulmonary hypertension due to left heart disease I27.23 Pulmonary hypertension due to lung diseases and hypoxia I27.24 Chronic thromboembolic pulmonary hypertension I27.29 Other secondary pulmonary hypertension I27.81 Cor pulmonale (chronic) I27.82 Chronic pulmonary embolism I27.83 Eisenmenger's syndrome I27.89 Other specified pulmonary heart diseases I42.0 Dilated cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I42.4 Endocardial fibroelastosis I42.5 Other restrictive cardiomyopathy I42.7 Cardiomyopathy due to drug and external agent I42.8 Other cardiomyopathies I43 Cardiomyopathy in diseases classified elsewhere I50.1 Left ventricular failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified J80 Acute respiratory distress syndrome J96.00 Acute respiratory failure, unspecified with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.21 Acute and chronic respiratory failure with hypoxia

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 5 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 5 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division J96.22 Acute and chronic respiratory failure with hypercapnia O90.3 Peripartum cardiomyopathy R06.00 Dyspnea, unspecified R06.01 Orthopnea R06.02 Shortness of breath R06.09 Other forms of dyspnea T86.20 Unspecified complication of heart transplant T86.21 Heart transplant rejection T86.22 Heart transplant failure T86.23 Heart transplant infection T86.290 Cardiac allograft vasculopathy T86.298 Other complications of heart transplant T86.30 Unspecified complication of heart-lung transplant T86.31 Heart-lung transplant rejection T86.32 Heart-lung transplant failure T86.33 Heart-lung transplant infection T86.39 Other complications of heart-lung transplant Z45.010 Encounter for checking and testing of cardiac pacemaker pulse generator [battery] Z45.018 Encounter for adjustment and management of other part of cardiac pacemaker Z48.21 Encounter for aftercare following heart transplant Z48.280 Encounter for aftercare following heart-lung trans plant Z94.1 Heart transplant status Z94.3 Heart and lungs transplant status Z95.0 Presence of cardiac pacemaker

REFERENCES

1. ACCF/AHA (2013) ACCF/AHA Practice Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128, e240 - e327. Accessed January 25, 2021. Available at URL Address: https://circ.ahajournals.org/content/128/16/e240.full#sec-51

2. ACC/AHA/HFSA Clinical Practice Guideline: (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. JACC, 70(6)2017. http://dx.doi.org/10.1016/j.jacc.2017.04.025. Accessed January 25, 2021. Available at URL Address: http://www.onlinejacc.org/content/accj/70/6/776.full.pdf?_ga=2.227685725.1511290437.1549 916677-1819188278.1519830351

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 6 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 6 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division 3. Agency for Healthcare Research and Quality. Thoracic Electrical Bioimpedance for Cardiac Output Monitoring. July 2, 2002 (rev. November 27, 2002). Accessed January 25, 2021. Available at: http://www.cms.gov/determinationprocess/downloads/id14TA.pdf

4. Centers for Medicare & Medicaid Services (CMS). Retired Local Coverage Determination (LCD) for Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (L29106). Contractor Name: First Coast Service Options, Inc. Primary Geographic Jurisdiction: Puerto Rico. Original Determination Effective Date: For services performed on or after 03/02/2009. Revision Effective Date: For services performed on or after 10/01/2011. Retirement Date: 08/25/2015 Accessed January 25, 2021. Available at URL address: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=29106%3a10

5. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) (20.16). Version Number 3. Effective Date of this Version: 11/24/2006. Implementation Date: 1/16/2007. Accessed January 25, 2021. Available at URL address: https://www.cms.gov/medicare-coverage- database/details/ncd- details.aspx?NCDId=267&ncdver=3&DocID=20.16&clickon=search&bc=gAAAAAgAAAAAAA%3d %3d&

6. Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub 100-20 One-Time Notification. Transmittal 1580. Subject: ICD-10 Conversion/Coding Infrastructure Revisions to National Coverage Determinations (NCDs)--3rd Maintenance CR. Date: December 3, 2015. Accessed January 25, 2021. Available at URL address: https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R1580OTN.pdf

7. Heart Failure Society of America. (2010). Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure, 16(6), 475 – 539. Accessed January 25, 2021. Available at URL Address: https://hfsa.org/sites/default/files/media/2015/04/Executive- Summary.pdf, and at URL Address: https://hfsa.org/heart-failure-guidelines-2010

8. Intensive Care Unit. Emergency Diagnosis and Treatment. Thermodilution: Methods and applications. Posted on September 20, 2008. Accessed January 25, 2021. Available at URL Address: https://intensivecareunit.wordpress.com/2008/09/20/thermodilution-methods-and- applications/

9. Pugsley, J. & Lerner, A.B. (2010). Cardiac Output Monitoring: Is There a Gold Standard and How Do the Newer Technologies Compare? Seminars in Cardiothoracic and Vascular Anesthesia. 14(4) 274 – 282. Accessed January 25, 2021. Available at URL Address: https://journals.sagepub.com/doi/pdf/10.1177/1089253210386386

10. MedicineNet. (2018) Definition of Cardiac Output. Last Editorial Review: 12/27/18. Accessed January 25, 2021. Available at URL Address: https://www.medicinenet.com/script/main/art.asp?articlekey=7524

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 7 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 7 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division 11. Mehta, Y., & Arora, D. (2014). Newer methods of cardiac output monitoring. World journal of cardiology, 6(9), 1022–1029. doi:10.4330/wjc.v6.i9.1022. Accessed January 25, 2021. Available at URL Address: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176793/

12. National Institute for Health and Care Excellence. (2018). NICE guidelines [NG106]. Chronic heart failure in adults: Diagnosis and management. Published date: September 12, 2018. Accessed January 25, 2021. Available at URL Address: https://www.nice.org.uk/guidance/ng106

13. Philips. (2004, October) Package Insert. ICG Impedance Cardiography - Non-invasive hemodynamic measurements. Accessed January 25, 2021. Available at URL Address: http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577243/577247/5826 46/583147/PM_-_ICG_Brochure.pdf%3fnodeid%3d585359%26vernum%3d-2

14. Sean-Xavier Neath, MD, PhD; Lucia Lazio, RN; David A. Guss, MD. (2005). Utility of Impedance Cardiography to Improve Physician Estimation of Hemodynamic Parameters in the Emergency Department. CHF. 11(1): 17-20. Accessed on January 21, 2021. Available at URL Address: https://www.medscape.com/viewarticle/500457

15. Stevanović, P., Šćepanović, R., Radovanović, D., Bajec, D., Perunović, R., Stojanović, D., & Stevanović, D. (2008). Thoracic electrical bioimpedance theory and clinical possibilities in perioperative medicine. Signa Vitae, 3(Suppl 1) S 22-27. Accessed January 25, 2021. Available at URL address: https://hrcak.srce.hr/file/31966

POLICY HISTORY DATE ACTION COMMENT

March 18, 2010 Origination of Policy March 23, 2011 Revised Section II under Indications added to policy. March 16, 2012 Yearly Revision Annual 2012 ICD-9-CM Updated. Diagnosis code 414.4 added. March 8, 2013 Revised References updated. Added new reference: number 3.

To Coding Information: Added new ICD-9 Code 425.18. February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was added to the policy. June 6, 2014 Revised References updated. New reference was added, number 2.

From Heading deleted statement: This policy is consistent with CMS’s Local Coverage Determination (LCD) on measurement of cardiac output monitoring by Thoracic Electrical Bioimpedance (TEB).

To the Description Section, added the corresponding citation: (ECRI, 2012).

To the Indications & Limitations Section, added the corresponding citation: (CMS L29106, 2011).

To the Limitations Section:

 Added to Limitation #1: e. In the management of all forms of hypertension (with the exception of drug- resistant

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 8 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 8 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division hypertension as outlined below, and Indication #6): Drug resistant hypertension is defined as failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a diuretic (CMS NCD 20.16, 2007).  Added to Limitation #1: f. All other uses of TEB not otherwise specified (CMS NCD 20.16, 2007).

To the Coding Information Section:

 Added the following ICD-9 Codes: 398.99, 403.10, 403.90, 404.10, 404.90, 414.2, 414.3, 414.9, 415.13, 424.1, & 425.9.  To Note 1 added the corresponding citation: (CMS L29106, 2011).  Added the following ICD-10 Codes: I26.02 & I26.92.

November 23, 2015 Revised To the coding section:  Eliminate ICD-9 codes since they are no longer valid for diagnosis classification.  Add new section of ICD-10 codes which are the valid diagnosis classification system since October 1, 2015.

May 12, 2016 Revised To the Description Section: New information was added to the description eliminating the Old one that was extracted from the Source ECRI Institute. 1. In the First Paragraph: The amount of blood the heart pumps through the circulatory system in a minute. The amount of blood put out by the left ventricle of the heart in one contraction is called the stroke volume. The stroke volume and the heart rate determine the cardiac output. A normal adult has a cardiac output of 4.7 liters (5 quarts) of blood per minute (MedicinetNet, 2012).

2. In the Second Paragraph: Thermodilution is an indicator-dilution method of measuring blood flow. This method is based on the premise that when an indicator substance is added to circulating blood, the rate of blood flow is inversely proportional to the change in concentration of the indicator over time. The indicator substance can be a dye (dye-dilution method) or a fluid with a different temperature than blood (thermodilution method). A dextrose or saline solution that is colder than blood is injected through the proximal port of the catheter in the right atrium. The cold fluid mixes with blood in the right heart chambers, and the cooled blood is ejected into the pulmonary artery and flows past the thermistor on the distal end of the catheter. The thermistor records the change in blood temperature with time and sends this information to an electronic instrument that record and displays a temperature-time curve. The area under this curve is inversely proportional to the rate of blood flow in the pulmonary artery. In the absence of intracardiac shunts, this flow rate is equivalent to the (average) cardiac output. (Russell, 2008).

3. In the Third Paragraph: Impedance cardiography (ICG), also referred to by the broader term, Thoracic Electrical Bioimpedance (TEB), is a noninvasive means of measuring cardiac output and other functional parameters. A small electric current is applied to the chest through electrodes placed on the neck and sides of the chest. Resistance to the current (impedance) is measured through

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 9 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 9 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division sensors also placed on the neck and sides of the chest. The pulsatile flow of blood causes fluctuations in the current, and the device calculates cardiac output from the impedance waveform. ICG is used in the management of several heart- related conditions, including CHF, pacemaker calibration, and heart transplant (Philips, 2004).

To the Limitations Section: 1. To the Point 1.C : This information was removed; it is not included in the NCD 20.16: Surgery patients while on a machine (since the device does not render accurate measurements under this circumstance). 2. To the Point 1.D: Letter D was deleted from the Policy.

To the Coding Information: ICD-10 Codes R06.00, R06.01, R06.02, R06.09 and Z95.0 were added to the Policy.

To the References Section: New References #1, 2, 5, 6, 7, 8, 9, and 13 were added to the Policy.

August 1, 2017 Revised To the Coding Information: To the ICD-10 Codes Section: The Following ICD-10 Codes were added to the Policy: A18.84, E78.00, E78.01, E78.1, E78.2, E78.3, E78.4, E78.5, E78.6, E78.70, E78.71, E78.72, E78.79, E78.81, E78.89, I16.0, I16.1, I16.9, I27.0, I27.1, I27.2, I27.81, I27.82, I27.89, I47.0, I47.1, I47.2, I47.9, I48.0, I48.1, I48.2, I48.3, I48.4, I48.91, I48.92, I49, I49.01, I49.02, I49.1, I49.2, I49.3, I49.40, I49.49, I49.5, I49.8, I49.9, I97.2, I97.3, I97.410, I97.411, I97.418, I97.42, I97.51, I97.52, I97.610, I97.611, I97.618, I97.620, I97.621, I97.622, I97.630, I97.631, I97.638, I97.640, I97.641, I97.648, I97.710, I97.711, I97.790, I97.791, I97.810, I97.811, I97.820, I97.821, I97.88, I97.89, J80, J96.00, J96.01, J96.02, J96.21, J96.22 and O90.3.

The Following ICD-10 Codes were deleted from this Policy: I01.0, I01.1, I01.2, I01.8, I01.9, I05.0, I05.1, I05.2, I05.8, I05.9, I07.0, I07.1, I07.2, I07.8, I07.9, I08.1, I08.2, I08.3, I09.1, I09.89, I09.9, I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I25.10, I25.110, I25.111, I25.118, I25.119, I25.3, I25.41, I25.42, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.84, I25.89, I25.9, I26.01, I26.02, I26.09, I26.90, I26.92, I26.99, I30.0, I30.1, I30.8, I30.9, I31.0, I31.1, I31.2, I31.3, I31.4, I31.8, I31.9, I32, I33.0, I33.9, I34.0, I34.1, I34.2, I34.8, I34.9, I35.0, I35.1, I35.2, I35.8, I35.9, I36.0, I36.1, I36.2, I36.8, I36.9, I37.0, I37.1, I37.2, I37.8, I37.9, I38, I39, I40.0, I40.1, I40.8, I40.9, I41, I42.3, I42.4, I42.6, I42.9, I50.20, I51.7, I51.81, I60.00, I60.01, I60.02, I60.10, I60.11, I60.12, I60.20, I60.21, I60.22, I60.30, I60.31, I60.32, I60.4, I60.50, I60.51, I60.52, I60.6, I60.7, I60.8, I60.9, J81.0, J95.84, M32.11, M32.12, N26.2, R06.00, T80.0XXA, T81.718A, T81.72XA, T82.817A, T82.818A and Z45.02.

To the References Section: New References #3 and 6 were added to the Policy.

February 23, 2019 Revised References Updated. Deleted #1, 11. Added #2 & #11.

To the Indications Section:

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 10 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 10 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division  To indications set I, #6: Added term blood pressure.

To the Coding Section:  Deleted ICD-10 Codes: E78.4, I27.2, I47.0, I47.1, I47.2, I47.9, I48.0, I48.1, I48.2, I48.3, I48.4, I48.91, I48.92, I49, I49.01, I49.02, I49.1, I49.2, I49.3, I49.40, I49.49, I49.5, I49.8, I49.9, I97.0, I97.110, I97.111, I97.120, I97.121, I97.130, I97.131, I97.190, I97.191, I97.2, I97.3, I97.410, I97.411, I97.418, I97.42, I97.51, I97.52, I97.610, I97.611, I97.618, I97.620, I97.621, I97.622, I97.630, I97.631, I97.638, I97.640, I97.641, I97.648, I97.710, I97.711, I97.790, I97.791, I97.810, I97.811, I97.820, I97.821, I97.88, I97.89  Added: E78.41, E78.49, I27.20, I27.21, I27.22, I27.23, I27.24, and I27.29. June 26, 2019 Revised To the Coding Section: The following ICD-10 Codes were added to the Policy: I27.83.

The following ICD-10 Codes were deleted from this Policy: E78.00, E78.01, E78.1, E78.2, E78.3, E78.41, E78.49, E78.5, E78.6, E78.70, E78.71, E78.72, E78.79, E78.81, and E78.89.

To the References Section:

The following references were added to the Policy: #11 and 14. May 13, 2020 Revised To the Coding Section: The following ICD-10 Codes were added to the Policy: R06.00. February 9, 2021 Revised No changes were made to the 2021 Update.

References were Updated and review the information contained in this Policy.

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 11 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 11 All Rights Reserved®