Blue Cross Blue Shield MA Transesophageal Echocardiography Coverage

Medical Necessity / Coverage Criteria

Mitral valve disease

Covered when ALL of the following are met for mitral valve disease

Mitral valve disease: TEE is medically necessary when needed to assess the etiology of mitral regurgitation and when needed to assist in the surgical decision making (mitral valve repair vs. replacement).

Endocarditis

Covered when ANY of the following high-suspicion or specific conditions apply

Endocarditis: TEE is medically necessary when suspicion of endocarditis is high and TTE does not document endocarditis; for re-evaluation in complex endocarditis; for evaluation of bacteremia without known source; and for evaluation of suspected or actual prosthetic valve endocarditis obscured on TTE due to reverberations or image artifacts.

TEE may define small vegetations and delineate local complications (e.g., ring abscesses, aneurysm, fistulae).

Valvular prostheses

Covered when ALL of following are met for prosthetic valves

Prosthetic valve evaluation: TEE is medically necessary in the evaluation of suspected prosthetic valve dysfunction when therapeutic decisions are critical and TTE is inconclusive and/or when the left atrium must be well-visualized.

TEE is not routinely indicated in all patients with prosthetic valves.

Suspected cardiac thrombi and emboli

Covered when ANY of the following apply regarding suspected thrombi/emboli

Cardiac thrombi/emboli: TEE is medically necessary to evaluate the left atrium and atrial appendage for clot when clot is not visualized on TTE or in patients with atrial fibrillation/flutter; to evaluate for an ASD, PFO, or atrial septal aneurysm with clot; and to evaluate the mitral valve in patients with a history of emboli.

Cardiac/pericardial masses and pericardial disease

Covered when ANY of the following apply for cardiac/pericardial masses or pericardial disease

Cardiac/pericardial masses: TEE is medically necessary for visualization of left atrial masses when needed to guide therapy (e.g., cystic vs. solid, attachment, infiltration); when cardiac mass lesions including valvular tumors are suspected but not visualized on TTE; and to assess pericardial effusion when surface studies do not provide adequate information.

Use of echocardiographic guidance may reduce pericardiocentesis risk, particularly for loculated or small effusions (ACC/AHA/ASE guidance).

Aortic and great vessel conditions

Covered when ANY of the following aortic or great vessel conditions are present or TTE is inadequate

Aortic/great vessel disease: TEE is medically necessary when TTE does not adequately visualize the aortic root; for identification of aortic dissection, ulceration, atherosclerotic plaque, or mural thrombus; for examination of the entire aorta (especially in emergencies); to visualize descending thoracic aortic aneurysms; for visualization of SVC/IVC including thrombosis or tumor extension; to visualize pulmonary veins; for evaluation after blunt chest trauma; and when needed to assist in surgical planning prior to aortic valve intervention.

TEE has a high sensitivity and specificity for aortic dissection.

Congenital heart disease

Covered when ANY of the following apply in congenital heart disease

Congenital heart disease: TEE is medically necessary for patients in whom TTE is technically inadequate or anatomic definition is incomplete; when more precise definition of atrial, outflow tract, or proximal pulmonary vascular anomalies is critical to management; for postoperative evaluation when TTE is limited by artifacts or prostheses; and to assess specific congenital complications (e.g., shunt flow across ASD, guidance of device closure, diagnosis of cor triatriatum, pulmonary valve abnormalities).

Critically ill patients

Covered when ANY of the following apply in critically ill patients

Critically ill: TEE is medically necessary for management when TTE is contraindicated (e.g., major trauma) or inadequate (e.g., ventilated patients, severe COPD, postoperative patients who cannot be positioned); for persistent hypoxemia when a right-to-left shunt is suspected; for complications of myocardial infarction (ruptured septum, papillary muscle, free wall); for hemodynamically unstable patients with suboptimal TTE images; for evaluation of brain-dead potential cardiac donors; and for persistent unexplained fever when endocarditis or myocardial abscess is suspected and TTE is nondiagnostic.

Interventional and intraoperative TEE

Covered when ANY of the following interventional or intraoperative indications apply

Interventional and surgical guidance: TEE is medically necessary for guidance during percutaneous cardiac interventions (creation of shunts, placement of septation devices, valvuloplasty, endomyocardial biopsy, electrophysiologic procedures, placement of septal or atrial appendage occluders, and percutaneous valve replacement); for intraoperative evaluation of prosthetic or repaired valves and complex congenital repairs; for intraoperative assessment of cardiopulmonary circulation during lung or heart-lung transplants; for intraoperative assessment of outflow tract obstruction or intracardiac shunts; and for intraoperative assessment of wall motion abnormalities after chest closure if acute deterioration occurs.

Doppler and 3-dimensional echocardiography; cardioversion

Covered/Investigational statements regarding ancillary techniques

Doppler/3D/TEE for cardioversion: Spectral Doppler and color flow-velocity mapping may be necessary as part of an echocardiographic examination when they contribute diagnostic information; Doppler may be considered not medically necessary if documentation does not show use or clinical necessity. Three-dimensional echocardiography when used with TEE is medically necessary for specific indications (pre-operative mitral repair planning, mitral stenosis assessment, ASD planning, interventional planning, intraoperative mapping for atrial ablation, tricuspid evaluation), whereas 3D echocardiography performed alone is NOT MEDICALLY NECESSARY. TEE is medically necessary for cardioversion in defined scenarios: urgent (not emergent) cardioversion without extended anticoagulation, prior cardioembolic events related to intra-atrial thrombus, contraindication to anticoagulation affecting the decision, or prior intra-atrial thrombus on TEE.

TEE is investigational for screening without established signs/symptoms, for routine serial pericardial assessment unless specific, and for aortic root dilation in connective tissue syndromes if TTE is adequate.

Medical Necessity Criteria for TEE

Covered when ALL of the following are met

General coverage logic: 1) The requested TEE procedure code is one of the listed CPT/HCPCS codes; 2) The submitted ICD-10 diagnosis code is among those listed as medically necessary for that CPT; 3) Medical necessity criteria are met (TEE is expected to provide information not available with TTE or less invasive imaging and will significantly contribute to management); 4) The study is performed by a properly trained examiner and includes a permanent record, sufficient data to support conclusions, and a written interpretation/report.

Procedure and diagnosis code pairing required; see Billing and Coding Article A52868 for full covered diagnosis codes.

Congenital Anomalies Coverage

For CPTs specific to congenital cardiac anomalies

Congenital CPT pairing: Procedure codes 93315-93317 and C8926 require submission with appropriate congenital ICD-10 diagnosis codes (Q20–Q24 series) to be considered medically necessary. Note: any procedure code from column 1 must be accompanied by any procedure code from column 2 to be considered medically necessary per policy note.

See Billing and Coding Article A52868 for full covered diagnosis codes.

Transesophageal echocardiography (TEE) is considered investigational for screening or to identify structural cardiac abnormalities when there are no established diagnoses, signs, or symptoms that justify the study. The policy also considers TEE investigational for routine serial assessment or management of pericardial pathology unless there are specific circumstances (for example, loculated posterior effusions or when transthoracic echocardiography [TTE] does not provide adequate visualization), and for evaluation of aortic root dilation in connective tissue disorders when TTE yields clinically sufficient information.

To qualify as a valid echocardiographic service, the TEE must be performed for an accepted clinical indication by a properly trained examiner and must include a permanent record of findings, data sufficient to support the conclusions, and an appropriate interpretation and written report. Studies that lack an accepted clinical indication or these documentation elements do not meet the requirements for a valid echocardiographic service and may be denied.

When used with TEE, three-dimensional (3D) echocardiography is considered medically necessary for specific preoperative and intraoperative planning indications (for example, mitral valve repair planning, mitral stenosis area assessment, ASD procedural planning, interventional device planning, atrial ablation mapping, and tricuspid valve evaluation). However, 3D echocardiography performed alone is NOT MEDICALLY NECESSARY. Additionally, the policy notes that Doppler/color flow-velocity mapping may be necessary when it contributes significant diagnostic information, but the Doppler portion may be considered not medically necessary if documentation does not show use of the technique or clinical necessity.

TEE is not medically necessary when it will not provide information beyond that available from transthoracic echocardiography (TTE) or other less invasive imaging modalities, or when it will not significantly contribute to patient management. If TTE adequately addresses the clinical question, TEE should not be performed solely for convenience or routine use.

Procedure and Diagnosis Codes

Covered CPT/HCPCS Codes (when medical necessity met)CPTCovered

93312	Echocardiography, transesophageal, real-time with image documentation (2d) (with or without m-mode recording); including probe placement, image acquisition, interpretation and report.
93313	Echocardiography, transesophageal; placement of transesophageal probe only.
93314	Echocardiography, transesophageal; image acquisition, interpretation and report only.
C8925	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2d); including probe placement, image acquisition, interpretation and report.

Example ICD-10 Diagnosis Codes considered medically necessary when criteria metICD-10

I01.0	Acute rheumatic pericarditis.
I01.8	Other acute rheumatic heart disease.
I01.9	Acute rheumatic heart disease, unspecified.
I28.8	Other diseases of pulmonary vessels.
I28.9	Disease of pulmonary vessels, unspecified.
I33.9	Acute and subacute endocarditis, unspecified.
I51.9	Heart disease, unspecified.
I67.9	Cerebrovascular disease, unspecified.

Covered CPT/HCPCS Codes (general adult)mixedCovered

93312	Echocardiography, transesophageal, real-time with image documentation (2d) (with or without m-mode recording); including probe placement, image acquisition, interpretation and report.
93313	Echocardiography, transesophageal; placement of transesophageal probe only.
93314	Echocardiography, transesophageal; image acquisition, interpretation and report only.
C8925	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast; including probe placement, image acquisition, interpretation and report.

Covered CPT/HCPCS Codes (congenital anomalies)mixedCovered

93315	Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report.
93316	Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only.
93317	Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only.
C8926	Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report.

3D rendering (add-on) CPT CodesCPT

76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation. (paired with 93312)
76377	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. (paired with 93314/93317)

ICD-10 Diagnosis Codes considered medically necessary when submitted with above CPTsICD-10Covered

I01.0	Acute rheumatic pericarditis.
I01.8	Other acute rheumatic heart disease.
I01.9	Acute rheumatic heart disease, unspecified.
I28.8	Other diseases of pulmonary vessels.
I28.9	Disease of pulmonary vessels, unspecified.
I33.9	Acute and subacute endocarditis, unspecified.
I51.9	Heart disease, unspecified.
I67.9	Cerebrovascular disease, unspecified.
Q20.9	Congenital malformation of cardiac chambers and connections, unspecified.
Q21.8	Other congenital malformations of cardiac septa.

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Appropriateness — When TEE is medically necessary

When medically necessaryTEE is medically necessary when there is a reasonable expectation it will provide information not available with TTE or other less invasive imaging and will significantly contribute to management decisions.

Requirement for examiner and recordTo qualify as a valid echocardiographic service, the study must be performed by a properly trained examiner and include a permanent record, sufficient data to support conclusions, and an appropriate written interpretation/report.

Use when TTE inadequateTEE is frequently performed because TTE was not technically adequate; TEE is preferred for conditions where TTE does not yield needed visualization (e.g., posterior structures, aortic root).

Relation to less invasive imagingTEE should be expected to provide information not available with TTE or other less invasive forms of imaging to meet appropriateness criteria.

Provider Requirements and Administrative Actions

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required for inpatient TEE services; outpatient prior authorization is not required for Commercial members.

Inpatient: precertification/preauthorization IS REQUIRED for all products when procedure is performed inpatient.
Outpatient: Commercial Managed Care (HMO and POS), PPO, and Indemnity — prior authorization is not required for outpatient TEE.

Denial Risk

Medical Necessity Required for Listed Procedure Codes

The above medical necessity criteria MUST be met for the listed CPT/HCPCS codes to be covered for Commercial Members.

Covered CPT/HCPCS codes include 93312, 93313, 93314, 93315, 93316, 93317, C8925, C8926 (see coding section for full descriptions).
Inclusion of a code does not guarantee coverage; verify member contract benefits.

Background

Transesophageal echocardiography (TEE) is an ultrasonic examination in which the transducer is positioned in the esophagus to obtain views of the heart that are different from and often superior to transthoracic echocardiography (TTE) for posterior structures. TEE provides enhanced visualization of the left atrium, pulmonary veins, mitral valve, aortic root, and the ascending and descending aorta, and is used when TTE is inconclusive or technically inadequate for diagnosis, surgical planning, or intraoperative guidance.

Definitions

Transesophageal Echocardiography (TEE) — definition and brief description

Definition (concise)An echocardiographic technique in which an ultrasound transducer is positioned in the esophagus to obtain high‑resolution images of cardiac structures and great vessels, often when TTE is inadequate.

Typical applicationsProvides improved visualization of posterior structures (left atrium, pulmonary veins, mitral valve), aortic root, ascending/descending aorta and arch; used for diagnosis, surgical planning and intraoperative guidance.

Ancillary techniquesMay be performed with Doppler and 3‑dimensional imaging when clinically indicated; 3D TEE is medically necessary for specific pre-/intra‑operative planning but 3D alone is not medically necessary.

Investigational limitsTEE is investigational for screening without established signs/symptoms and for certain serial assessments of pericardial pathology unless specific indications exist.

Transesophageal echocardiography (TEE) — ultrasonic examination with esophageal transducer placement

References and Revision History

This policy was updated to a new medical policy effective 10/1/2024, with an administrative update to reference links (L33579 and A52868). It should be read with related Blue Cross Blue Shield — Massachusetts policies including Policy 115 (Transthoracic Echocardiography), the Local Coverage Determination L33579, and the Billing and Coding article A52868, which provide complementary guidance on when TTE is adequate and on covered diagnosis codes for TEE.

2024-10-01policy_addedLatest

New medical policy describing medically necessary and investigational indications (effective 10/1/2024).

2019-10-01last_revision

Last revision of the policy recorded (policy history endnote lists last revision 10/1/2019).