DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Microvolt T‑Wave Alternans (MTWA) Testing — Coverage Criteria

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Policy governing coverage and medical necessity of MTWA testing (spectral analytic method) for risk assessment of ventricular arrhythmias and sudden cardiac death for Blue Cross & Blue Shield of Rhode Island products, distinguishing Medicare Advantage and Commercial Products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrovolt T‑Wave Alternans (MTWA) Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2026

Last ReviewMar 6, 2026

Next Review DateMar 6, 2026

Key ActionPrior authorization is recommended for Commercial Products for MTWA testing (CPT 93025).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1CPT code listed for MTWA

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DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Microvolt T‑Wave Alternans (MTWA) Testing — Coverage Criteria

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Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

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Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrovolt T‑Wave Alternans (MTWA) Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2026

Last ReviewMar 6, 2026

Next Review DateMar 6, 2026

Key ActionPrior authorization is recommended for Commercial Products for MTWA testing (CPT 93025).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1CPT code listed for MTWA

16Specific not medically necessary indications

>=110 bpmProvocative heart rate

>=3Positive threshold

Coverage Criteria for MTWA Testing

Commercial Products — MTWA for ICD evaluation

Covered when ALL of the following are met:

Commercial Products - general medical necessity: MTWA testing using the spectral analytic method is considered medically necessary for the evaluation of persons at risk of sudden cardiac death for medically necessary implantable cardioverter-defibrillator placement.

Applies to spectral analytic method and when medical criteria are met; prior authorization is recommended for Commercial Products (CPT 93025).

Medicare Advantage — Coverage

Medicare Advantage: MTWA testing is covered for Medicare Advantage Plans; BCBSRI follows CMS determinations.

CPT 93025 is listed as a covered code for Medicare Advantage Plans.

MTWA testing using the spectral analytic method is considered not medically necessary for a list of specific indications where evidence is insufficient to support improved health outcomes. These include: diagnosis and risk assessment of acute coronary syndrome; diagnosis of reversible myocardial ischemia in individuals without structural heart disease; evaluation of non‑pathological preterm infants; evaluation of children and adolescents with Eisenmenger syndrome; evaluation of malignant ventricular arrhythmias in Chagas disease; evaluation of the adequacy of medical therapy; guidance of anti‑arrhythmic therapy; judgment of the severity of ischemic cardiomyopathy; prediction of major adverse cardiac events in ischemic heart failure; prediction of post‑operative mortality in cardiac surgery; prognosis of myocardial function in newborns with hypoxic‑ischemic encephalopathy; prognosis of pulmonary arterial hypertension; prognostic evaluation in hypertrophic cardiomyopathy; risk assessment of sudden cardiac death in children with chronic renal failure; risk stratification after repair of tetralogy of Fallot; risk stratification in Brugada syndrome; and tracking changes in risk during cardiac disease progression.

Coverage and payment for MTWA testing are subject to the member's subscriber agreement, member certificate, and/or employer agreement, which take precedence over this medical policy. For member‑specific benefits and eligibility, providers must contact the provider call center. If services are determined to be not medically necessary or are otherwise non‑covered under the member's plan, those services may be denied and providers may not bill the member unless the member has been informed and provided written agreement in advance.

MTWA combined with electrophysiologic study for prediction of ventricular tachyarrhythmias in individuals with arrhythmogenic right ventricular cardiomyopathy is considered not medically necessary because the evidence is insufficient to determine effects on health outcomes.

Coding and Test Parameters

Covered CPT CodesCPTCovered

93025

Microvolt T-wave alternans for assessment of ventricular arrhythmias

inv-08: Provocative heart rate — required heart rate during MTWA testing

Required provocative heart rate> 110 beats per minute (heart rate must be gradually elevated above this level during MTWA testing)

Method of provocationGradual elevation of heart rate; test can be performed with exercise tolerance stress testing

Purpose of provocationProvocation to elicit beat-to-beat T-wave alternans not detectable on routine ECG

inv-09: Alternans ratio threshold — typical threshold considered a positive MTWA result

Typical positive thresholdAlternans ratio ≥ 3 (number of SDs by which peak T‑wave signal exceeds background noise)

Reporting conventionsAn alternans ratio of 3 or greater is typically considered a positive result; absent = negative; other values = indeterminate

Provider Actions, Authorization, and Denial Risk

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for Commercial Products for MTWA testing (CPT 93025). Providers should obtain prior authorization when required by the member's plan.

Affected CPT: 93025

Note

Use in Evaluation for ICD Placement

MTWA using the spectral analytic method is considered medically necessary for the evaluation of persons at risk of sudden cardiac death for consideration of implantable cardioverter‑defibrillator (ICD) placement when the medical criteria in this policy are met.

Documentation Required

Required Test Method and Reporting

Background on MTWA Testing

Microvolt T‑wave alternans (MTWA) measures beat‑to‑beat variability in T‑wave amplitude at the microvolt level using specialized sensors and computer algorithms. Testing is performed during gradual heart‑rate provocation and results are reported as an alternans ratio (the number of standard deviations by which the peak T‑wave signal exceeds background noise). The test requires raising heart rate to a target > 110 beats per minute, and an alternans ratio of approximately >= 3 is typically considered a positive result; results may also be interpreted as negative or indeterminate per the reporting algorithm.

Definitions and Measurement Terms

inv-19: Alternans ratio — number of SDs by which peak T-wave signal exceeds background noise; typical positive >=3.

DefinitionNumber of standard deviations (SDs) by which the peak T‑wave signal exceeds background noise

Typical positive cutoffAlternans ratio ≥ 3 is typically considered positive

Interpretation categories≥3 = positive; absent = negative; other values = indeterminate

Reporting formatExpressed numerically as the alternans ratio derived from specialized sensors and algorithms

inv-20: Microvolt T-wave alternans (MTWA) — definition describing beat-to-beat microvolt variability measured during heart-rate provocation.

DefinitionBeat-to-beat microvolt variability in T‑wave amplitude measured with specialized sensors and computer algorithms during heart‑rate provocation

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrovolt T‑Wave Alternans (MTWA) Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2026

Last ReviewMar 6, 2026

Next Review DateMar 6, 2026

Key ActionPrior authorization is recommended for Commercial Products for MTWA testing (CPT 93025).

SourceLink

On This Page

Measurement unitReported as number of standard deviations (SDs)

Test results should be reported as an alternans ratio (number of SDs the T‑wave signal exceeds background noise). An alternans ratio ≥ 3 is typically considered positive, an absent alternans ratio is negative, and intermediate values are indeterminate.

Denial Risk

Denial Risk When Criteria Not Met or for Listed Indications

MTWA testing using the spectral analytic method is considered medically necessary when the medical criteria in this policy are met and is considered not medically necessary when those criteria are not met. MTWA is not medically necessary for the listed indications where evidence is insufficient (e.g., diagnosis/assessment in acute coronary syndrome, guidance of anti‑arrhythmic therapy, risk stratification in various congenital or disease‑specific conditions). Providers should follow the medical necessity criteria to avoid denial risk.

Note

Verify Benefits / Prior Authorization

Verify member benefits and eligibility prior to providing services. Contact the provider call center or refer to the member's subscriber agreement/certificate for coverage details. If services are determined not medically necessary or are non‑covered, the provider may not charge the member unless the member was informed and provided written agreement in advance per the participation agreement.

Denial Risk

Denial and Member Charge Risk

Services determined not to be medically necessary or not covered under the member's benefit plan may be denied and could result in charges to the provider or member per contract terms. Providers should confirm coverage and obtain necessary authorizations to mitigate member/provider financial liability.

Detection requirementRequires specialized sensors and algorithms because routine ECG cannot detect microvolt-level fluctuations

ProvocationMeasured during gradual elevation of heart rate to >110 bpm; may be performed with exercise testing

Clinical useInvestigated as a risk factor for fatal arrhythmias and sudden cardiac death in patients with MI, heart failure, or cardiomyopathy

inv-21: MTWA — alternate definition and usage for arrhythmia risk assessment (additional definition entry).

Alternate definitionMicrovolt T‑wave alternans (MTWA) is a noninvasive test measuring beat‑to‑beat alternation in the T‑wave at the microvolt level used for arrhythmia risk stratification

Evidence baseReferenced in CMS NCD and BCBSA TEC assessments for risk stratification and ICD candidate evaluation

Typical clinical applicationUsed to evaluate persons at risk of sudden cardiac death and to help identify candidates for implantable cardioverter‑defibrillator placement

LimitationsRequires specialized sensors/algorithms; not detectable on routine ECG; evidence insufficient for many other indications