Cigna non-stress TTE Coverage Update

Medically Necessary Indications and Surveillance for TTE

ACC AUC – CHD: ASD/PAPVC/PFO

ACC AUC–based coverage criteria for transthoracic echocardiography (TTE) in congenital heart disease (CHD). The following condition-specific surveillance indications and timing are considered when determining medical necessity for non-stress TTE (with or without 3D; with contrast as needed). Scores/ratings are the ACC AUC score (1-9) and rating (A = Appropriate, M = May be Appropriate, R = Rarely Appropriate) and reflect the AUC recommendations.

Table 1: CHD — Patent Foramen Ovale (PFO), Atrial Septal Defect (ASD), Partial Anomalous Pulmonary Venous Connection (PAPVC) - Routine surveillance of an asymptomatic patient with PFO: TTE = 1/R; TTE with contrast = 1/R. - Routine surveillance (1-2 years) in asymptomatic patient with small ASD or PAPVC (single pulmonary vein): TTE = 4/M; TTE with contrast = Not rated. - Routine surveillance (3-5 years) in asymptomatic patient with small ASD or PAPVC (single pulmonary vein): TTE = 7/A; TTE with contrast = Not rated. - Evaluation due to change in clinical status and/or new concerning signs or symptoms: TTE = 8/9 = A; TTE with contrast = Not rated/5/M depending on specific scenario. - Evaluation to determine method of closure of isolated secundum ASD: TTE = 8/9 = A; TTE with contrast = Not rated/4/M as indicated. - Pre- and postprocedural surveillance: routine postprocedural evaluation within 30 days = 8/9 = A; selected routine follow-up timing after device/surgical closure at 1 week, 1 month, 3-6 months, 1 year and longer intervals per AUC (ratings vary: many 8/9 = A; some Not rated or lower ratings for contrast).

ACC AUC – CHD: Ventricular Septal Defects

Table 2: CHD — Ventricular Septal Defects (VSD). Condition-specific surveillance and evaluation indications.

Routine surveillance (1-2 years) in asymptomatic child with small muscular VSD: TTE = 3/R. Routine surveillance (3-5 years) in asymptomatic child or adult with small muscular VSD: TTE = 7/A. Routine surveillance (1-2 years) in asymptomatic child with small non-muscular VSD: TTE = 7/A (child) and adult 8/A as specified. Routine surveillance (1-3 months) in infant with ≥ moderate VSD on medical management: TTE = 9/A. Evaluation due to change in clinical status or prior to planned repair: TTE = 9/A. Postprocedural routine postprocedural evaluation (within 30 days): TTE = 9/A. Routine surveillance timing after surgical or device closure (within first year and then annually or 2-3 years) per AUC; ratings vary (commonly 8-9/A).

ACC AUC – CHD: Atrioventricular Septal Defects

Table 3: CHD — Atrioventricular Septal Defects (AVSD). Indications and surveillance timing.

Routine surveillance (3-6 months) in asymptomatic infant: TTE = 9/A. Routine surveillance (1-2 years) in asymptomatic child: TTE = 9/A. Evaluation due to change in clinical status, evaluation prior to planned repair, and routine postprocedural evaluation within 30 days: TTE = 9/A. Routine longer-term surveillance after repair: within 1 year and then 1–3 years (TTE = 9/A) when no or mild sequelae; increased frequency (3-12 months) for significant residual shunt, valvular/ventricular dysfunction, arrhythmias, or pulmonary hypertension (TTE = 9/A).

ACC AUC – CHD: Patent Ductus Arteriosus

Table 4: CHD — Patent Ductus Arteriosus (PDA). Surveillance by age, severity, and postprocedural status.

Routine surveillance (3-5 years) in asymptomatic patient with trivial, silent PDA: TTE = 3/R. Routine surveillance (3-6 months) in infant with ≥ moderate PDA: TTE = 9/A. Routine surveillance (3-6 months) in infant with small audible PDA until closure: TTE = 7/A. Routine surveillance (1-2 years) in infant/child with small audible PDA until closure: TTE = 8/A. Routine surveillance (3-5 years) in adult with small PDA: TTE = 9/A. Evaluation due to change in clinical status or prior to planned repair: TTE = 9/A. Postprocedural routine postprocedural evaluation within 30 days: TTE = 9/A. Routine longer-term surveillance after closure varies by device vs surgical repair and sequelae (ratings vary).

ACC AUC – CHD: Total Anomalous Pulmonary Venous Connection

Table 5: CHD — Total Anomalous Pulmonary Venous Connection (TAPVC). Indications for evaluation and routine surveillance.

Evaluation due to change in clinical status and/or new concerning signs or symptoms: TTE = 9/A. Evaluation prior to planned repair: TTE = 9/A. Routine postprocedural evaluation within 30 days: TTE = 9/A. Routine surveillance (3-6 months) in asymptomatic infant with no or mild sequelae: TTE = 8/A. Routine surveillance (1-2 years) in asymptomatic child with no or mild sequelae: TTE = 8/A.

ACC AUC – CHD: Eisenmenger Syndrome / Pulmonary Hypertension

Table 6: CHD — Eisenmenger Syndrome (ES) and pulmonary hypertension associated with CHD. Surveillance and evaluation guidance.

Initial evaluation with suspicion of ES: TTE = 9/A. Evaluation due to change in clinical status or change in PH-targeted therapy: TTE = 9/A. Routine surveillance: children—3 months when stable (some ratings 6/M, 9/A depending on age); adults—6-12 months when stable (ratings include 3/R and 9/A depending on context). For postoperative pulmonary hypertension or suspected PH following CHD surgery: initial evaluation and changes in therapy: TTE = 9/A; routine surveillance intervals per age and stability (3 months to 6-12 months) with ratings as specified.

ACC AUC – CHD: Ebstein Anomaly / Tricuspid Valve

Table 7: CHD — Ebstein Anomaly and Tricuspid Valve Dysplasia. Surveillance by age, symptom status, TR severity, and ventricular function.

Routine surveillance (1-2 years) in asymptomatic infant/child with mild tricuspid regurgitation (TR): TTE = 9/A; TTE with contrast = Not rated. Routine surveillance (3-5 years) in asymptomatic adult with mild TR: TTE = 9/A; TTE with contrast = 5/M. Routine surveillance (3-6 months) in asymptomatic infant with ≥ moderate TR without hypoxemia: TTE = 9/A; contrast not rated. Routine surveillance (6-12 months) in asymptomatic patient with ≥ moderate TR and previously stable RV size/function without hypoxemia: TTE = 9/A; TTE with contrast = 4/M. Evaluation due to change in clinical status or new concerning signs/symptoms: TTE = 9/A; TTE with contrast = 7/A where indicated. Evaluation of ASD for device closure in patient with mild/moderate TR and RV enlargement: TTE = 9/A.

ACC AUC – CHD: Pulmonary Stenosis

Table 8: CHD — Pulmonary Stenosis (PS). Surveillance by age and PS severity.

Routine surveillance (3-6 months) in asymptomatic infant with mild PS: TTE = 8/A. Routine surveillance (1-2 years) in asymptomatic child with mild PS: TTE = 8/A. Routine surveillance (3-5 years) in asymptomatic adult with mild PS: TTE = 9/A. Routine surveillance (3-6 months) in asymptomatic infant with ≥ moderate PS: TTE = 9/A. Routine surveillance (1-2 years) in asymptomatic child or adult with ≥ moderate PS: TTE = 9/A. Routine surveillance (3-5 years) in asymptomatic adult with PS and pulmonary artery dilation: TTE = 9/A. Evaluation for change in clinical status, pre-repair evaluation, and routine postprocedural within 30 days: TTE = 9/A. Routine surveillance intervals for sequelae and symptomatic patients vary (3-12 months) with TTE = 9/A.

ACC AUC – CHD: Pulmonary Atresia with Intact Ventricular Septum

Table 9: CHD — Pulmonary Atresia with Intact Ventricular Septum. Evaluation and surveillance guidance.

Evaluation prior to planned repair: TTE = 9/A. Routine postprocedural evaluation (within 30 days): TTE = 9/A. Routine surveillance (1-3 months) in asymptomatic patient: TTE = 9/A. Routine surveillance (3-6 months) in asymptomatic infant, and 1-2 years in asymptomatic child with no or mild sequelae: TTE = 9/A. Routine surveillance intervals for moderate/severe sequelae and symptomatic patients: TTE = 9/A with 3-12 month follow-up where indicated.

ACC AUC – CHD: Mitral Valve Disease

Table 10: CHD — Mitral Valve Disease (including congenital mitral stenosis [MS], mitral regurgitation [MR], mitral valve prolapse). Surveillance by age, severity, ventricular function, and prosthetic valve status.

Routine surveillance (1-4 weeks) in infant <3 months with any degree of MS: TTE = 8/A. Routine surveillance (3-6 months) in infant ≥3 months with mild MS: TTE = 8/A; (1-3 months) for ≥ moderate MS: TTE = 9/A. Routine surveillance (6-12 months) in asymptomatic infant with mild MR: TTE = 9/A; (1-3 months) for infant with ≥ moderate MR: TTE = 9/A. Routine surveillance (2-5 years) in child with mild MR and normal LV size/function: TTE = 9/A. Routine surveillance intervals for prosthetic mitral valves: annually or more frequent depending on dysfunction (many entries TTE = 9/A).

ACC AUC – CHD: LVOT / Aortic Valve Disease and Aortic Dilation

Table 11: CHD — Left Ventricular Outflow Tract (LVOT) lesions and Aortic Valve disease. Surveillance by lesion, age, severity, and aortic dilation.

Routine surveillance (1-3 months) in infant with any degree subvalvular aortic stenosis (AS) and ≤ mild AR: TTE = 9/A. Routine surveillance (1-2 years) in child/adult with mild subvalvular AS and no AR: TTE = 9/A. Routine surveillance (6-12 months) in child/adult with ≥ moderate subvalvular AS and/or ≤ mild AR: TTE = 9/A. Routine surveillance (3-5 years) in asymptomatic adult with ≥ moderate subvalvular AS: TTE = 9/A. Infant surveillance timing by degree of AS/AR: 1-4 weeks to 1-3 months depending on severity (many entries TTE = 9/A). Bicuspid aortic valve with aortic dilation: surveillance intervals for aortic sinus/ascending aorta per AUC (e.g., 6-12 months for increasing z-scores, 2-3 years for stable mild dilation); many entries TTE = 9/A or 3/R depending on specific scenario. Postoperative and postprocedural routine evaluation within 30 days: TTE = 9/A.

ACC AUC – CHD: Aortic Coarctation / Interrupted Aortic Arch

Table 12: CHD — Aortic Coarctation and Interrupted Aortic Arch. Surveillance and post-intervention follow-up guidance.

Routine surveillance (3-6 months) in infant with mild aortic coarctation without PDA: TTE = 9/A. Routine surveillance (1-2 years) in child/adult with mild coarctation: TTE = 9/A. Routine surveillance (3-6 months) within first year following repair in asymptomatic patient with no or mild sequelae: ratings vary (some entries Not rated; many 9/A for later intervals). Routine surveillance (6-12 months) within first year following catheter-based intervention: Not rated in some entries; later surveillance at 6 months and then 1-2 years after first year: TTE = 9/A. Routine surveillance (3-5 years) to evaluate for aortic arch aneurysms, in-stent stenosis, stent fracture, or endoleak: Not rated for some entries; escalate for symptoms (3-12 months) TTE = 9/A.

ACC AUC – CHD: Coronary Anomalies

Table 13: CHD — Coronary Anomalies. Surveillance by anomaly type and fistula size.

Routine surveillance (annually) in asymptomatic patient with anomalous right coronary artery from left aortic sinus: TTE = 3/R; routine surveillance (2-5 years) TTE = 7/A. Routine surveillance (annually) in asymptomatic patient with small coronary fistula: TTE = 3/R; routine surveillance (2-5 years) TTE = 8/A. Routine surveillance (1-2 years) in asymptomatic patient with moderate or large coronary fistula: TTE = 9/A. Evaluation due to change in clinical status, pre-repair evaluation, and routine postprocedural evaluation within 30 days: TTE = 9/A. Routine surveillance (1-3 months) within first year following repair: TTE = 7/A; routine longer-term surveillance intervals depend on sequelae and residual dysfunction.

ACC AUC – CHD: Tetralogy of Fallot

Table 14: CHD — Tetralogy of Fallot (TOF). Surveillance before and after repair and by sequelae.

Routine surveillance (1-3 months) in infant before complete repair and following interim procedures (valvuloplasty, RVOT stenting, shunt placement): TTE = 9/A. Postoperative initial repair surveillance within 30 days: TTE = 9/A. Routine surveillance annually in asymptomatic patient with no or mild sequelae or pulmonary regurgitation of any severity: TTE = 9/A. Routine surveillance (6-12 months) in patients with valvular dysfunction other than pulmonary valve, RVOT obstruction, branch pulmonary artery stenosis, arrhythmias, or RV-to-PA conduit: TTE = 9/A. Routine surveillance (2-3 years) for patients with pulmonary regurgitation and preserved ventricular function: some entries Not rated; for other sequelae interval commonly 1-3 years or 6-12 months depending on dysfunction (TTE = 9/A where noted). Evaluation prior to planned pulmonary valve replacement and postprocedural follow-up (1 year, 1 and 6 months after transcatheter replacement) per AUC: TTE = 9/A.

ACC AUC – CHD: Double Outlet Right Ventricle

Table 15: CHD — Double Outlet Right Ventricle (DORV). Surveillance and postoperative follow-up.

Routine surveillance (1-3 months) in infant with balanced circulation: TTE = 9/A. Routine surveillance (3-6 months) in child with balanced circulation: TTE = 9/A. Evaluation due to change in clinical status or prior to planned repair: TTE = 9/A. Routine postprocedural evaluation within 30 days: TTE = 9/A. Routine surveillance (6 months within first year) after repair in asymptomatic infant/child with no or mild sequelae: TTE = 9/A; longer-term intervals (1-2 years) in asymptomatic patients with no or mild sequelae: TTE = 9/A. More frequent surveillance (3-12 months) for valvular/ventricular dysfunction, RV/LV outflow obstruction, branch pulmonary artery stenosis, arrhythmias, or conduits: TTE = 9/A.

ACC AUC – CHD: D-Loop Transposition of the Great Arteries

Table 16: CHD — D-Loop Transposition of the Great Arteries (D-Loop TGA). Indications for evaluation, postoperative surveillance, and coronary imaging consideration.

Evaluation due to change in clinical status or prior to planned repair: TTE = 9/A. Postoperative arterial switch: routine postoperative evaluation within 30 days: TTE = 9/A. Routine surveillance (1-3 months) in asymptomatic infant with moderate sequelae: TTE = 9/A; (3-6 months) for infants with no or mild sequelae: TTE = 9/A. Routine surveillance (3-12 months) in older children/adults with ≥ moderate valvular/ventricular dysfunction, outflow obstruction, branch pulmonary artery stenosis, or arrhythmias: TTE = 9/A. Evaluation for coronary imaging in an asymptomatic patient: TTE = Not rated (alternative modalities may be considered per AUC).

ACC AUC – CHD: ccTGA

Table 17: CHD — Congenitally Corrected Transposition of the Great Arteries (ccTGA). Surveillance recommendations.

Evaluation due to change in clinical status: TTE = 9/A; TTE with contrast entries often Not rated. Routine surveillance (3-6 months) in asymptomatic infant: TTE = 9/A (contrast Not rated). Routine surveillance (1-2 years) in patient with < moderate systemic AV valve regurgitation: TTE = 9/A; contrast Not rated. Routine surveillance (6-12 months) in patient with ≥ moderate systemic AV valve regurgitation: TTE = 9/A; contrast Not rated. Routine surveillance (3-5 years) in asymptomatic patient: TTE = 9/A (contrast Not rated). Evaluation prior to planned repair and routine postprocedural follow-up per AUC: TTE = 9/A.

ACC AUC – CHD: Truncus Arteriosus

Table 18: CHD — Truncus Arteriosus. Indications for evaluation, postoperative, and surveillance.

Evaluation due to change in clinical status or prior to planned repair: TTE = 9/A. Routine postprocedural evaluation within 30 days: TTE = 9/A. Routine surveillance (1-3 months) within first year after repair in asymptomatic patient: TTE = 9/A. Routine surveillance (6-12 months) after first year in asymptomatic child/adult with no or mild sequelae: TTE = 9/A. Routine surveillance intervals (3-5 years) for stable asymptomatic patients may be Not rated in some entries; escalate frequency for moderate stenosis/regurgitation or residual defects (3-12 months) TTE = 9/A.

ACC AUC – CHD: Single-Ventricle Heart Disease

Table 19: CHD — Single-Ventricle Heart Disease. Surveillance and timing around staged palliation.

Routine surveillance (1-4 weeks) in patient with balanced systemic and pulmonary circulation not requiring neonatal surgery: TTE = 9/A (contrast Not rated). Evaluation due to change in clinical status or prior to planned surgical palliation: TTE = 9/A. Postprocedural (Stage 1 palliation) routine postprocedural evaluation within 30 days: TTE = 9/A. Routine surveillance (6 months within first year) after repair in asymptomatic infant/child with no or mild sequelae: TTE = 9/A. Longer-term surveillance intervals vary based on stage, residual lesions, and clinical status; more frequent imaging (3-12 months) for significant sequelae or symptoms.

CPT, HCPCS, and ICD-10 Coding for Echocardiography Services

Covered CPT CodesCPTCovered

93303	Transthoracic echocardiography for congenital cardiac anomalies; complete.
93304	Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study.
93306	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.
93307	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography.
93308	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study.
93319	3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or during transthoracic echocardiography for congenital cardiac anomalies (List separately).
93320	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately).
93321	Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study (List separately).
93325	Doppler echocardiography color flow velocity mapping (List separately).

Myocardial Strain (CPT 93356)CPTCovered

93356

Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging). Considered medically necessary when the primary TTE (93303, 93304, 93306, 93307, 93308) on the same date is medically necessary AND either: prior to, during or following exposure to medications/radiation that could result in cardiotoxicity; OR to evaluate hypertrophic cardiomyopathy. Not covered for other indications.

Covered HCPCS C-codesHCPCSCovered

C8921	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete.
C8922	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study.
C8923	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color doppler echocardiography.
C8924	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording when performed, follow-up or limited study.
C8929	Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography.

Covered ICD-10-CM Diagnosis Codes (selected device/complication codes)ICD-10Covered

T82.817A-T82.818S	Embolism due to cardiac and vascular prosthetic devices, implants and grafts.
T82.827A-T82.827S	Fibrosis due to cardiac prosthetic devices, implants and grafts.
T82.837A-T82.837S	Hemorrhage due to cardiac prosthetic devices, implants and grafts.
T82.847A-T82.847S	Pain due to cardiac prosthetic devices, implants and grafts.
T82.855A-T82.855S	Stenosis of coronary artery stent.
T82.857A-T82.857S	Stenosis of other cardiac prosthetic devices, implants and grafts.
T82.867A-T82.867S	Thrombosis due to cardiac prosthetic devices, implants and grafts.
T82.897A-T82.897S	Other specified complication of cardiac prosthetic devices, implants and grafts.
T82.9XXA-T82.9XXS	Unspecified complication of cardiac and vascular prosthetic device, implant and graft.
T85.730A-T85.738S	Infection and inflammatory reaction due to nervous system devices, implants and grafts.

Sample Covered ICD-10-CM Codes (Table 1 excerpts)ICD-10Covered

A18.84	Tuberculosis of heart.
A36.81	Diphtheritic cardiomyopathy.
B33.20-B33.24	Viral carditis.
C33-C34.92	Malignant neoplasm of trachea and bronchus/lung (selected ranges).
I42.1	Obstructive hypertrophic cardiomyopathy.

Coding Informationmixed

A transthoracic echocardiogram may be Considered Medically Necessary when criteria in the applicable policy statements listed above are met and when billed with a diagnosis code from Table 1.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Follow prior authorization / delegated vendor guidelines

Follow applicable utilization review and prior authorization processes used by Cigna or delegated vendors; coverage determinations may reference delegated vendor guidelines (e.g., eviCore) and ACC Appropriate Use Criteria/guidelines.

Documentation Required

Document surgical risk and prior testing (90–220 days)

When ordering perioperative or preprocedural TTE, document the patient’s surgical risk category and any prior testing performed within the prior 90–220 days to support the request.

Prior Authorization

Reference diagnosis, indication, and timing on prior auth

If prior authorization is required by the payer, include the specific congenital heart disease diagnosis, the clinical indication (surveillance, pre-repair, postprocedural, or change in status), and the timing relative to interventions when submitting the request.

Clinical Background and Guideline Context

Echocardiography is the most frequently used cardiac imaging modality for evaluation of structural, functional, and hemodynamic cardiac abnormalities. TTE (with or without 3D and with contrast as needed) is the primary initial and follow‑up imaging test cited throughout the policy and is referenced to support many of the ACC/AHA guideline‑based recommendations.

Key Terms and Definitions Used in This Policy

Myocardial strain definition and method variability

DefinitionMyocardial strain represents the percent change in myocardial length from relaxed to contractile state (deformation)

Method variabilityStrain values vary among methods, modalities, and software versions, limiting direct comparability

Primary clinical useMost prevalent use is identification of cancer therapy–related cardiac dysfunction

TTE definition (with/without 3D and contrast)

DefinitionTransthoracic echocardiography (TTE) comprises real-time 2D imaging with optional inclusion of 3D imaging and use of contrast-enhancing agents as needed

Modalities includedTTE technique family includes 2D imaging, spectral and color Doppler, tissue Doppler, 3D imaging, and myocardial strain imaging

Policy Updates and Material Changes

2025-02-15Annual Review - material scope changeLatest

Revised policy statement to include individuals undergoing nonemergent, noncardiac surgery and to include diagnosis and management of hypertrophic cardiomyopathy.

2024-02-15Annual Review - material addition

Added a policy statement for CAMZYOS (mavacamten) and reformatted the Coverage Policy section.

OpenPayer

Non-stress transthoracic echocardiography (TTE)