CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cardiac Hemodynamic Monitoring

This policy governs coverage and medical necessity determinations for outpatient cardiac hemodynamic monitoring technologies (implantable PA pressure sensors, thoracic bioimpedance, inert gas rebreathing, and LVEDP estimation via Valsalva) for heart failure management for BCBSRI products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCardiac Hemodynamic Monitoring

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2019

Next Review Date

Key ActionVerify member benefits and refer to the benefit booklet for contract-specific requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4monitoring modalities discussed

93701covered CPT (Medicare Adv)

33289,93264codes not covered

93799unlisted code recommended

Coverage Criteria — Cardiac Hemodynamic Monitoring

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inv-02: Implantable PA sensors; Inert gas rebreathing; Valsalva LVEDP

Implantable PA pressure sensors; Inert gas rebreathing; Valsalva LVEDP estimation: For Commercial Products: implantable pulmonary artery pressure sensors, inert gas rebreathing, and arterial pressure measurement during the Valsalva maneuver are considered not medically necessary because evidence is insufficient to determine effects on health outcomes.

Some implantable PA sensor devices (eg, CardioMEMS) have FDA marketing authorization, but overall outpatient outcome evidence is insufficient per policy.

inv-03: Coverage stance by plan type

Coverage distinctions by product:

TEB coverage: CPT 93701 (bioimpedance-derived physiologic cardiovascular analysis) is covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products.

Wireless pulmonary artery (PA) sensor — implantation and monitoring: CPT 93264 (remote monitoring of a wireless PA pressure sensor) and CPT 33289 (transcatheter implantation of a wireless PA pressure sensor) are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products.

When inert gas rebreathing or LVEDP estimation is performed, report with unlisted cardiovascular code 93799 as there are no specific CPT codes.

Cardiac hemodynamic monitoring modalities discussed in this policy include implantable pulmonary artery pressure sensors, thoracic electrical bioimpedance (TEB), inert gas rebreathing, and estimation of left ventricular end‑diastolic pressure (LVEDP) via the Valsalva maneuver. For these outpatient HF monitoring technologies the policy finds the evidence insufficient to determine effects on health outcomes, and therefore considers use of implantable PA pressure monitoring, inert gas rebreathing, and arterial pressure measurement during Valsalva to be not covered / not medically necessary for Commercial Products.

For management of heart failure, the policy summarizes coverage by modality: thoracic electrical bioimpedance (TEB), implantable PA pressure sensors, inert gas rebreathing, and LVEDP estimation via Valsalva. For Commercial Products all of these modalities are considered not medically necessary because the available evidence is judged insufficient to determine effects on health outcomes. Although some implantable PA sensor systems (for example CardioMEMS) have received FDA clearance or approval, the policy still concludes evidence is inadequate to support routine outpatient coverage.

Coding — CPT and Unlisted Codes

Covered CPT Codes (Medicare Advantage)CPTCovered

93701

Bioimpedance-derived physiologic cardiovascular analysis using _

Not covered / Not medically necessary CodesCPTNot Covered

93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician Or other qualified health care professional
33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensOr, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed

Unlisted codes (inert gas rebreathing, LVEDP)CPT

93799

Unlisted cardiovascular service Or procedure

Cardiac hemodynamic monitoring (TEB)CPTCovered

93701

Bioimpedance-derived physiologic cardiovascular analysis using _

Wireless pulmonary artery pressure sensor — implantation and monitoringCPTNot Covered

93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician Or other qualified health care professional
33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensOr, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed

Unlisted cardiovascular servicesCPT

93799

Unlisted cardiovascular service Or procedure

Provider Actions — Billing, Authorization, Reporting

Prior Authorization

Prior Authorization / Benefit Verification

Prior Authorization: Not applicable for this policy.

Benefits may vary between groups and contracts — verify member benefits and eligibility prior to services; refer to the applicable Benefit Booklet or Evidence of Coverage.
For Medicare Advantage members: CPT 93701 (bioimpedance-derived physiologic cardiovascular analysis) is covered by Medicare Advantage but considered not medically necessary for Commercial Products.

Denial Risk

Claims for Implantation / Remote Monitoring — Denial Risk

Claims for implantation and remote monitoring of a wireless pulmonary artery pressure sensor are at high risk of denial for Medicare Advantage members and are considered not medically necessary for Commercial Products. Submit claims only when consistent with member benefits and medical necessity documentation.

CPT 33289 — Transcatheter implantation of wireless pulmonary artery pressure sensor: NOT COVERED for Medicare Advantage; NOT MEDICALLY NECESSARY for Commercial Products.
CPT 93264 — Remote monitoring of a wireless pulmonary artery pressure sensor (up to 30 days): NOT COVERED for Medicare Advantage; NOT MEDICALLY NECESSARY for Commercial Products.

Billing Rule

Procedure Reporting and Coding Notes

Procedure reporting and coding guidance: implantable pulmonary artery pressure sensors (e.g., CardioMEMS) are implanted via right heart catheterization with device deployment and calibration. There is no specific CPT for inert gas rebreathing or direct LVEDP measurement; use the unlisted cardiovascular code when reporting these services.

When reporting LVEDP approximation via implantable sensor or inert gas rebreathing, report as 93799 (Unlisted cardiovascular service or procedure).
If implantation involves right heart catheterization components, ensure accompanying catheterization and angiography codes are documented as appropriate; include operative and device documentation to support coding choices.

Documentation Required

Reporting Unlisted Procedures

Reporting unlisted procedures: there is no specific code for inert gas rebreathing measurement or left ventricular end-diastolic pressure; report using the unlisted cardiovascular code and include operative notes, device details, and rationale for the unlisted code.

Use CPT 93799 for inert gas rebreathing or LVEDP estimation when no specific CPT exists.
Attach detailed documentation (procedure description, findings, device model/implantation details, and time/date of service) to support medical necessity when using an unlisted code.

Background — Rationale and Intended Use

Outpatient cardiac hemodynamic monitoring devices are intended to detect physiologic changes that precede clinical heart failure decompensation so that early, preemptive interventions can be undertaken. Techniques described in this policy — implantable pulmonary artery sensors, thoracic bioimpedance, inert gas rebreathing for cardiac output estimation, and arterial pressure responses during Valsalva to approximate LVEDP — are all aimed at identifying hemodynamic deterioration before symptomatic worsening.

Definitions — Modalities and Codes

inv-23: Thoracic bioimpedance (impedance cardiography) — definition and measurement summary

DefinitionMeasurement of electrical resistance across the thorax; beat-to-beat changes in impedance are inversely related to pulsatile changes in blood volume and velocity in the aorta, allowing calculation of stroke volume and cardiac output (also called impedance cardiography).

Physiologic basisSmall electrical signals traverse the thorax via the blood-filled aorta (most conductive path); changes in thoracic bioimpedance tracked each heartbeat reflect aortic pulsatile volume and velocity changes.

Clinical useUsed to estimate stroke volume and cardiac output; cardiac output can be reduced in systolic heart failure and declines further with acute decompensation.

Alternate nameImpedance cardiography (TEB).

inv-24: Inert gas rebreathing — definition of technique for cardiac blood flow measurement

DefinitionTechnique in which absorption kinetics of a blood-soluble inert gas during rebreathing are measured to compute cardiac blood flow (cardiac output).

Method summaryPatient breathes from a rebreathing bag containing oxygen plus fixed proportions of two inert gases (typically nitrous oxide [blood-soluble] and sulfur hexafluoride [insoluble]); concentrations are measured continuously to determine gas uptake proportional to blood flow.

Measured parametersSimultaneous measurement of soluble and insoluble gas concentrations (and carbon dioxide) at the mouthpiece to determine volume of gas exchange and derive cardiac flow.

inv-25: LVEDP estimation via Valsalva — noninvasive estimation method definition

DefinitionNoninvasive estimation of left ventricular end-diastolic pressure (LVEDP) using arterial pressure responses recorded during the strain phase of repeated Valsalva maneuvers.

RationaleArterial pressure during the Valsalva strain phase may directly reflect LVEDP; analysis of these responses produces values that correlate with invasively measured LVEDP.

Clinical contextDeveloped as an outpatient-friendly alternative to invasive catheter measurement, which is not practical for routine outpatient use.

inv-26: 93701 — code definition for bioimpedance-derived physiologic cardiovascular analysis (TEB)

CPT code93701

Short descriptionBioimpedance-derived physiologic cardiovascular analysis (cardiac hemodynamic monitoring using thoracic electrical bioimpedance).

Coverage note93701 is covered for Medicare Advantage Plans and considered not medically necessary for Commercial Products per policy coding guidance.

Reporting guidanceUsed to report thoracic electrical bioimpedance (TEB) cardiac hemodynamic monitoring services; other hemodynamic modalities use different or unlisted codes.