Echocardiography Med202.024 ______Coverage

ECHOCARDIOGRAPHY MED202.024 ______COVERAGE:

The following echocardiography procedures may be eligible for coverage:

· Transthoracic echocardiography (TTE) M-Mode

· Transthoracic echocardiography (TTE) 2D

· Stress Echocardiography

· Dobutamine Stress Echocardiography

· Doppler echocardiography (pulsed wave, continuous wave, or color flow velocity)

· Contrast Echocardiography

· Transesophageal echocardiography (TEE)

· Fetal echocardiography, and

· 3-D echocardiography ______DESCRIPTION:

Echocardiography is a painless diagnostic procedure which uses high frequency sound waves (ultrasound-principle similar to sonar or radar) to take moving pictures of the heart. The sound waves are directed towards the heart from a small hand-held device, which sends and receives these signals. This device is called a transducer. Objects, such as the heart walls and valves, reflect part of the sound waves back to the transducer where they are used to produce pictures of the heart.

Echocardiography is used for the following indications:

· Evaluation of murmurs and valvular heart disease · Pericardial effusion · Congestive heart failure · Left ventricular and left atrial size, wall thickness · Idiopathic hypertrophic subaortic stenosis (IHSS) · Identification of thrombus (e.g. recent stroke), myxomas and vegetation · Ischemic heart disease (functional evaluation of wall motion) · Post traumatic evaluation to identify abnormalities of wall motion or significant effusion. · Chest pain with clinical evidence of valvular, pericardial, or primary myocardial disease · Chest pain with suspected acute myocardial ischemia · Chest pain with suspected aortic dissection · Chest pain with severe hemodynamic instability · Multi-vessel coronary artery disease · Stenosis, regurgitation, valve dehiscence, and/or infection of prosthetic heart valves · Follow-up of allograft recipient – Heart transplant

The following types of echocardiography are clinically used:

· Transthoracic Echocardiography M-mode provides a one-dimensional view (depth) into the heart. The M-mode images represent echoes from various tissue interfaces along the axis of the beam. These echoes, which move during the cardiac cycle, are swept across time on the oscilloscope/recording, providing the dimension of time.

· Transthoracic Echocardiography Two-dimensional allows a plane of tissue (both depth and width) to be imaged. Thus, the orientation and anatomic relationships between various structures are easier to appreciate.

· Stress Echocardiography involves performing transthoracic echocardiography before and after cardiovascular stress. It is typically used for detection of coronary artery disease, or in determining the impact that a myocardial infarction may have had with respect to cardiovascular performance.

· Dobutamine Stress Echocardiography is a variation of stress echocardiography. Some patients are unable to exercise to the needed degree to unmask coronary artery blockages due to medical illnesses. Dobutamine helps by mimicking the effects of exercise. An intravenous line is placed and dobutamine is infused. The heart is then imaged at different stages with a transthoracic echocardiogram.

· Doppler echocardiography, using the same or similar ultrasound transducers may be done where the sound waves are used to judge the speed, amount, and direction of the blood cells flowing through parts of the heart and great vessels. This test is used to determine any heart defect, valve abnormalities or abnormalities of the pumping chambers of the heart. Doppler is for use in adults and pediatric patients for measuring cardiac output, measuring intracardiac flow velocities, calculation intracardiac pressure variations, and diagnosing and assessing the severity of valvular and other structural (e.g., septal defects) abnormalities.

· Contrast Echocardiography refers to the injection of an ultrasound contrast agent into the blood stream. Ultrasound contrast agents typically are composed of a solution of microbubbles or occasionally air filled microspheres. Current agents include simple agitation of sterile saline, which is very frequently used for detecting shunts inside the heart. This type of contrast echo is also used to make doppler signals more obvious. There are new contrast agents, which can enhance the ability of an echocardiogram to identify the walls of the heart.

· Transesophageal Echocardiography (TEE) is more complex then transthoracic echocardiography. It provides a superb view of many structures of the heart, which are not available from transthoracic echocardiography. A TEE is performed by mounting a miniaturized ultrasound transducer on the end of a gastroscope. To perform a transesophageal echocardiogram the patient must swallow the endoscopic probe. This is usually undertaken after the patient has been sedated. TEE is used for the following indications:

Aortic dissection Acute endocarditis Thromboembolic accidents Valvular heart disease Mitral incompetence Suspicion of dysfunction of a prosthetic valve Monitoring, intraoperatively or in intensive care

· Fetal Echocardiography is a non-invasive technique for diagnosing and assessing cardiac abnormalities in the fetus. Fetal echocardiography is performed using two-dimensional echocardiography. It is used in cases where high risk of congenital heart disease is present.

· Three-Dimensional Echocardiography is a new technology which uses high-speed computers and new reconstruction techniques which allows an echocardiogram to be obtained as a three-dimensional image. Specific areas where this may play a role include identifying the precise abnormalities present in patients with complex forms of congenital heart disease, determining the exact mechanism by which a valve leaks blood and in determining the success of some types of cardiac surgery. ______RATIONALE:

Echocardiography is an important non-invasive tool for imaging the heart and surrounding structures. It can be quite helpful in establishing a specific diagnosis and determining the severity of various cardiac diseases. ______DISCLAIMER:

State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, takes precedence over Medical Policy and must be considered first in determining coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Any benefits are subject to the payment of premiums for the date on which services are rendered. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. HMO Blue Texas physicians who are contracted/affiliated with a capitated IPA/medical group must contact the IPA/medical group for information regarding HMO claims/reimbursement information and other general polices and procedures. ______Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association ______Posted Jan. 7, 2003