Alliance Health ECG Echo IVUS Coverage Update

Coverage Criteria and Medical Necessity

Covered when policy criteria are met

Policy contains General and Specific Criteria Covered sections and identifies modality‑specific coverage sections (electrocardiography, echocardiography, coronary IVUS, fetal echo).

Document structure: Coverage sections include General Criteria Covered (3.1) and Specific Criteria Covered (3.2) with modality subsections (electrocardiography, echocardiography, coronary intravascular ultrasound, fetal echocardiography).

Details of specific clinical criteria are in the modality subsections.

General medical necessity

Medicaid covers procedures when medically necessary and the following are met:

General criteria: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Electrocardiogram (ECG) coverage

Medicaid shall cover electrocardiograms when:

ECG indications: 1. evaluation of signs and symptoms related to, and disorders of, cardiac rhythm, anatomy, coronary blood flow, and myocardial function; OR 2. as an adjunct in the assessment of certain drug toxicities and metabolic disorders.

Amended Date: November 1, 2023.

Cardiovascular Stress Test coverage

Medicaid shall cover cardiovascular stress testing for any of the following indications:

Stress test indications: 1. screening for coronary atherosclerosis and myocardial ischemia; 2. follow-up post-myocardial infarction (MI), post-PTCA, or post-CABG to assess functional improvement during cardiac rehabilitation; 3. follow-up of beneficiaries with palliated or unpalliated congenital heart disease; 4. follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy; 5. follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; 6. pre-operative assessment of beneficiaries considered for valve replacement; 7. follow-up after valve replacement.

Microvolt T-Wave Alternans

Medicaid shall cover microvolt T‑wave alternans when ALL of the following are met:

T-wave alternans criteria: 1. used to identify the risk of ventricular arrhythmias and sudden cardiac death; 2. the beneficiary meets criteria for implantable cardioverter defibrillator (ICD) placement; and 3. the spectral analytic method is used.

See Attachment A, letter B, for allowed diagnosis codes.

Holter Monitor coverage

Medicaid shall cover Holter monitoring when ALL of the following are met:

Holter criteria: 1. the physician suspects a cardiac etiology for the beneficiary's symptoms (e.g., palpitations, dizziness, or syncope); AND 2. the symptoms are frequent enough to expect capture during the Holter monitoring time period.

See Attachment A, letter B, for allowed diagnosis codes.

Ambulatory Event Monitor coverage

Medicaid shall cover event monitoring when ALL of the following are met:

Event monitor criteria: 1. the physician suspects a cardiac etiology for the beneficiary's symptoms (e.g., palpitations, dizziness, or syncope); 2. the events are unpredictable or infrequent such that a Holter monitor may not capture them but frequent enough that event monitoring would capture them; 3. the symptoms are of sufficient severity that documenting a cardiac etiology will alter clinical management; and 4. the beneficiary (or parent/guardian) can identify symptoms and activate the event monitor.

See Attachment A, letter B, for allowed diagnosis codes.

Echocardiography modalities coverage

Medicaid shall cover the following echocardiography uses by modality:

TTE indications: Assessment of cardiac chamber sizes; evaluation of left ventricular hypertrophy; evaluation of stenotic or insufficient valves; identification of atrial or ventricular masses or thrombi; identification of pericardial disorders; identification and assessment of congenital heart defects; identification and assessment of abnormal physiology (e.g., pulmonary hypertension); guidance of percutaneous interventions directly affecting the heart.

TEE indications: Evaluation of bacterial endocarditis; identification of left atrial pathology; evaluation of valvular prosthesis; evaluation of the aortic arch and descending thoracic aorta for dissection, thrombi, or friable plaques; evaluation of cardiac structure in critically ill ventilated beneficiaries; identification and assessment of congenital heart defects; assessment of cardiac anatomy and function before and after cardiac surgery.

Doppler/Color Doppler indications: Evaluation of septal defects; evaluation of severity of valve stenosis or regurgitation; evaluation of site of left-to-right or right-to-left shunts; assessment of diseases of the aorta; evaluation of prosthetic valves; assessment of congenital heart defects.

Doppler procedures are add-on codes and must be billed with the primary procedure (see billing limits).

Fetal Echocardiography coverage

Fetal echocardiography is covered as a diagnostic ultrasound test to evaluate fetal heart structure and physiology.

Fetal echo uses: Diagnostic evaluation of fetal cardiac defects using high-resolution 2-D ultrasound with color Doppler to identify abnormal connections or valve abnormalities and spectral Doppler to assess fetal blood flow velocities and physiology; may include imaging of umbilical, hepatic vessels and middle cerebral artery as part of a complete fetal echogram.

Refer to clinical coverage policy 1E-4 for fetal surveillance using Doppler echocardiography.

Coronary Intravascular Ultrasound (IVUS)

IVUS is covered as an intravascular imaging modality for coronary arteries when clinically indicated.

IVUS description: An intravascular imaging modality using a catheter with a distal miniaturized ultrasound probe to produce images from inside coronary arteries for assessment of stent deployment, restenosis mechanisms, plaque and calcium distribution, evaluation of lesions difficult to image by angiography, and assessment of atherosclerosis extent.

See Attachment A, letter B, for allowed diagnosis codes when applicable.

Doppler/Color Echocardiography - Covered Indications

Medicaid shall cover Doppler or color Doppler echocardiography for any of the following:

Doppler/Color Echocardiography Indications: Evaluation of septal defects; evaluation of severity of valve stenosis or regurgitation; evaluation of site of left-to-right or right-to-left shunts; assessment of diseases of the aorta; evaluation of prosthetic valves; assessment of congenital heart defects.

Doppler procedures are add-on codes and must be billed with the primary procedure by the same physician.

Intracardiac Echocardiography - Covered Indications

Medicaid shall cover intracardiac echocardiography for any of the following:

Intracardiac Echocardiography Indications: Evaluation of septal defects; evaluation of severity of valve stenosis or regurgitation; evaluation of site of left-to-right or right-to-left shunts; assessment of diseases of the aorta; evaluation of prosthetic valves; assessment of congenital heart defects; and guidance of therapeutic catheter-based interventions.

Intracardiac echo is an add-on code and must be billed with the primary procedure by the same physician; limited to one per day for guidance of a catheter-based intervention.

Coronary IVUS - Covered Indications

Medicaid shall cover coronary IVUS for any of the following:

Coronary IVUS Indications: Assessment of adequacy of stent deployment including extent of stent apposition and minimum luminal diameter; determination of mechanism of stent restenosis and selection of appropriate therapy; evaluation of coronary obstruction difficult to image by angiography in suspected flow-limiting stenosis; assessment of suboptimal angiographic result after percutaneous interventions; establishment of coronary arterial calcium distribution when considering rotational atherectomy; determination of plaque location and circumferential distribution for directional atherectomy guidance; determination of extent of atherosclerosis in patients with anginal symptoms and positive functional study with no focal stenosis or only mild CAD on angiography.

See Attachment A, letter B, for allowed diagnosis codes.

Fetal Echocardiography - Covered Indications

Medicaid shall cover fetal echocardiography for any of the following:

Fetal Echocardiography Indications: a. suspected congenital heart disease based on obstetrical screening; b. elevated fetal risk factors (e.g., abnormal nuchal thickness, chromosomal abnormality, other fetal structural abnormalities); c. elevated maternal risk factors (e.g., pregestational diabetes, teratogen exposure); d. elevated family risk factors (e.g., previous child or first-degree relative with congenital heart disease); e. elevated risk for acquired fetal heart disease (e.g., maternal autoimmune disease or infectious exposure).

Refer to clinical coverage policy 1E-4 for fetal surveillance details.

Transthoracic Echocardiography

TTE limits

TTE per day limit: Transthoracic echocardiography is limited to one per day.1 per day

Repeat allowed only when medically necessary and must be amended with modifier 76 or 77 (examples: transfer to tertiary hospital, change in clinical status, guidance during interventional procedure).

Transesophageal Echocardiography

TEE limits

TEE screening limit: Transesophageal echocardiography is limited to one per day for screening purposes.1 per day (screening)

Two intraoperative TEEs are allowed per day when performed during cardiac surgery if documented preoperative and postoperative components; only the first intraoperative TEE can include the probe placement code.

Doppler Echocardiography

Doppler echocardiography billing

Doppler add-on reporting: Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure; they are not to be reported as a stand‑alone code and must be reported by the same physician.n/a

Primary codes are identified in the CPT Manual.

Intracardiac Echocardiography

Intracardiac echocardiography billing

Intracardiac echo per day limit and billing: Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter‑based intervention and is an add‑on code that must be listed with the primary procedure by the same physician; it is not to be reported as a stand‑alone code.1 per day

Primary codes are identified in the CPT Manual.

Fetal Echocardiography

Fetal echocardiography limits

Fetal echo per day limit: Fetal echocardiography is limited to one per day.1 per day

A repeat test is allowed only when medically necessary and must be amended with modifier 76 or 77 (examples: transfer to tertiary hospital, change in fetal clinical status, guidance during interventional procedure). Refer to policy 1E-4 for fetal surveillance specifics.

Coronary Intravascular Ultrasound (IVUS) - limits and billing

Coronary IVUS limits and billing

IVUS per day and vessel limits: One IVUS (initial vessel) is allowed per day plus up to three additional vessels per day when performed with the initial vessel IVUS.1 initial + up to 3 additional vessels per day

IVUS is an add‑on code and must be listed separately in addition to the primary procedure by the same physician; includes all transducer manipulations and repositioning within the examined vessel.

The policy includes a dedicated section titled When the Procedure, Product, or Service Is Not Covered (Section 4.0), with subsections for General Criteria Not Covered (4.1) and Specific Criteria Not Covered (4.2). These sections define situations where services under this policy are ineligible for coverage.

Under the EPSDT special provision (applicable to beneficiaries under age 21), Medicaid must cover medically necessary services to correct or ameliorate conditions identified by screening. EPSDT, however, does not require coverage of services that are unsafe, ineffective, experimental or investigational, or not generally recognized as accepted medical practice.

General exclusions include services for beneficiaries who do not meet eligibility (Section 2.0) or the policy criteria (Section 3.0), duplicate services, or services that are experimental, investigational, or part of a clinical trial. Specific not-covered examples called out in Section 4.1–4.2 include: microvolt T-wave alternans when used for general assessment of atherosclerotic heart disease, congestive heart failure, or pre-surgical evaluation; Holter monitoring for periods less than 24 hours; home-based telemetry; and coronary IVUS for pre-interventional device selection or for diagnosis after cardiac transplantation.

The policy specifies that certain procedures are add-on codes and are excluded from stand-alone reporting. Doppler (color) echocardiography, intracardiac echocardiography, and coronary IVUS must be listed in addition to an identified primary procedure; they are not to be reported as standalone codes and must be reported by the same physician who performed the primary procedure.

A Not Covered / Not Medically Necessary section is included in the policy (Section 4.0). It defines the framework for exclusions and points readers to the general and specific criteria that render a procedure not covered under this policy.

Microvolt T-wave alternans is explicitly listed as not covered when used for routine or general assessment—specifically for evaluating atherosclerotic heart disease, congestive heart failure, or for pre-surgical screening. The procedure is also not covered as part of routine physicals or routine stress testing.

Codes, Allowed Diagnoses, and Billing Limits

Codes referenced in Attachment Amixed

CPT (various)

Allowed diagnosis codes referenced in Attachment Amixed

No codes listed

Allowed diagnosis codes referenced for IVUSmixed

No codes listed

Doppler add-on codesCPT

add-on (unspecified)

Doppler echocardiography add-on codes (specific CPTs identified in CPT Manual)

Intracardiac echo add-on codesCPT

add-on (unspecified)

Intracardiac echocardiography add-on codes (specific CPTs identified in CPT Manual)

Coronary IVUS add-on codesCPT

add-on (unspecified)

Coronary IVUS add-on codes (specific CPTs identified in CPT Manual)

Selected ICD-10-CM and related procedure codes (excerpt)mixed

93025	Microvolt T-Wave Alternans
I47.20	Ventricular tachycardia, unspecified
I47.21	Torsades De Pointes
I47.29	Other ventricular tachycardia
I47.0	Re-entry ventricular arrhythmia (example from list)

Electrocardiography CPT Codes and mappingsCPT

93000	Electrocardiography Codes mapping listed
93005	Electrocardiography Codes mapping listed
93010	Electrocardiography Codes mapping listed
93015	Electrocardiography Codes mapping listed
93016	Electrocardiography Codes mapping listed
93017	Electrocardiography Codes mapping listed
93018	Electrocardiography Codes mapping listed
93025	Electrocardiography Codes mapping listed
93040	Electrocardiography Codes mapping listed
93041	Electrocardiography Codes mapping listed

Echocardiography CPT Codes and mappingsCPT

93303	Echocardiography Codes mapping listed
93304	Echocardiography Codes mapping listed
93306	Echocardiography Codes mapping listed
93307	Echocardiography Codes mapping listed
93308	Echocardiography Codes mapping listed
93312	Echocardiography Codes mapping listed
93313	Echocardiography Codes mapping listed
93314	Echocardiography Codes mapping listed
93315	Echocardiography Codes mapping listed
93316	Echocardiography Codes mapping listed

1–10 of 18

1/2

Fetal Echocardiography CPT CodesCPT

76820	Fetal Echocardiography Codes mapping
76821	Fetal Echocardiography Codes mapping
76825	Fetal Echocardiography Codes mapping

Coronary Intravascular Ultrasound CPT CodesCPT

92978	Coronary Intravascular Ultrasound CPT code
92979	Coronary Intravascular Ultrasound CPT code

Selected ICD-10-CM diagnosis codes referenced for T-wave alternans and microvolt testingICD-10

I49.02	T-Wave Alternans - primary diagnosis allowed
I50.9	Microvolt T-Wave Alternans - primary diagnosis allowed
I49.2	Microvolt T-Wave Alternans mapping

Holter monitoring duration

Allowed duration24–48 hours

Report contentsRecorder with chest leads connected for continuous ambulatory monitoring

PurposeDescribe overall rhythm and significant arrhythmias

Event monitor duration

Maximum monitoring period

Prior Approval, Documentation, and Billing Guidance

Prior Authorization

Eligibility Verification

Verify each beneficiary's Medicaid eligibility at the time of service. Eligibility must be confirmed for every encounter; services may be denied if the beneficiary is not enrolled, or if their eligibility category restricts the requested service.

Providers shall verify enrollment in the NC Medicaid Program for each service rendered.
Service restrictions may apply based on the beneficiary's eligibility category.

Denial Risk

IVUS — Denial Risks and Billing Requirements

Coronary IVUS may be denied when used for pre-interventional assessment of lesion characteristics and vessel dimensions solely to select a revascularization device, or for diagnosis of coronary disease after cardiac transplantation. Ensure IVUS is billed only as an add‑on with an appropriate primary procedure code and reported by the same physician; do not bill IVUS as a stand‑alone code.

Definitions and Modalities

Electrocardiography definition and types

DefinitionA procedure for recording electrical changes in the heart; the ECG/EKG shows waveforms that relate to electrical impulses during each heartbeat

Primary useEvaluate and detect cardiac problems such as rhythm disturbances

Modality noteIncludes routine (≥12 leads) and rhythm (1–3 leads) electrocardiograms

Echocardiography definition

DefinitionDiagnostic test using ultrasound waves to create images of the heart to assess size, shape, valve and chamber motion

PurposePermits full assessment of the heart and accurate diagnosis of certain cardiovascular diseases

Background and Policy Scope

Electrocardiography, echocardiography, and intravascular ultrasound serve distinct diagnostic roles. An electrocardiogram (ECG) records the heart's electrical activity to evaluate rhythm and conduction. Echocardiography (including transthoracic and transesophageal approaches, Doppler/color flow, intracardiac, and fetal echocardiography) uses ultrasound to image cardiac structure and function and to assess valves, chambers, masses, shunts, and hemodynamics. Coronary intravascular ultrasound (IVUS) is a catheter-based intravascular imaging modality that produces cross-sectional images from inside coronary arteries to assess stent deployment, restenosis mechanisms, plaque and calcium distribution, and other vessel-specific features; IVUS is performed as an add-on during invasive coronary procedures.

OpenPayer

Electrocardiography, Echocardiography, and Intravascular Ultrasound

Coverage Criteria and Medical Necessity

Codes, Allowed Diagnoses, and Billing Limits

Prior Approval, Documentation, and Billing Guidance

Definitions and Modalities

Background and Policy Scope

Policy Revision History