ModifiedCignaPolicy 0270

Tilt table testing for syncope

This Cigna medical coverage policy governs use of tilt table testing (with or without pharmacologic provocation) for diagnosis and evaluation of syncope for members covered by Cigna benefit plans.

Policy Summary

PayerCigna

PolicyTilt table testing for syncope

Policy CodePolicy 0270

Change TypeCombined policyremoved computerized dynamic posturography statement

Effective DateDec 15, 2024

Next Review DateDec 15, 2025

Key ActionProviders must submit appropriate diagnosis and procedure codes and verify prior authorization requirements for CPT 93660 when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Removed policy statement for computerized dynamic posturography.

Combined with Tilt Table Testing policy; title updated.

0270Coverage Policy Number

12/15/2024Effective

1Primary ICD-10 example (R55)

93660Primary procedure code

Annual 12/15/2024

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Coverage Criteria for Tilt Table Testing

Medically Necessary Indications

Tilt table testing with or without provocative agents is considered medically necessary for the evaluation of syncope when ANY of the following are met:

Indication list: 1) Individual with or without structural heart disease when the cause of syncope has not been established after a complete history and physical examination and appropriate diagnostic testing, including a 12‑lead ECG, echocardiogram, and formal exercise tolerance testing; 2) Individual in whom a suspected cause of syncope (e.g., asystole or high‑degree AV block) has already been established, but results of tilt table testing are needed to determine the treatment plan; 3) Differentiation of convulsive syncope from epilepsy.

May be performed with or without pharmacologic provocation (e.g., isoproterenol).

Not Covered Indications

Tilt table testing is not covered or reimbursable for ANY other indication including the following:

Not covered indications: single syncopal episode when clinical features support a diagnosis of vasovagal syncope; syncope in which a specific alternate cause has been established and in which demonstration of neurally mediated syncope would not alter the treatment plan; evaluation of unexplained recurrent falls without a history of symptoms associated with vasovagal syncope; recurrent near syncope or dizziness presumed neurally mediated; evaluation of unexplained syncope when neuropathies or dysautonomias may contribute to symptomatic hypotension; follow-up evaluation of therapy to prevent syncope recurrences; chronic fatigue syndrome; recurrent vertigo; recurrent transient ischemic attacks.

Explicit non-covered list.

Tilt table testing is not covered or reimbursable for a number of specific, inappropriate uses. These include evaluation for chronic fatigue syndrome, recurrent vertigo, and recurrent transient ischemic attacks. The test is also excluded for follow-up evaluation of therapy to prevent syncope recurrences, assessment of unexplained recurrent falls without a history of vasovagal symptoms, and for recurrent near syncope or dizziness presumed neurally mediated. Additionally, tilt table testing is not covered when syncope has a specific alternate cause already established and demonstrating neurally mediated syncope would not change the treatment plan.

Specific ICD-10-CM diagnosis codes listed under the policy section titled Not Covered or Reimbursable are explicitly excluded from coverage and reimbursement for tilt table testing.

Tilt table testing is considered not medically necessary for a single syncopal episode when clinical features support vasovagal syncope. It is likewise not necessary when the cause of syncope is already attributed to a specific alternate diagnosis and demonstrating neurally mediated syncope would not alter management, or when testing is sought for isolated evaluations such as unexplained recurrent falls without vasovagal symptoms, or for presumed neurally mediated near syncope or dizziness.

Use of any diagnosis codes designated in the policy’s Not Covered or Reimbursable section will render tilt table testing not reimbursable / not covered; documentation and coding must avoid these disallowed ICD-10-CM codes when seeking coverage for the procedure.

Coding — Covered and Not Covered Codes

Considered Medically Necessary when criteria are metCPTCovered

93660

Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention

Example covered ICD-10-CM diagnosisICD-10Covered

R55	Syncope and collapse

Not Covered or Reimbursable ICD-10-CM codesICD-10Not Covered

No codes listed

Not Covered Diagnosis CodesICD-10Not Covered

ICD-10-CM

Not Covered or Reimbursable: diagnosis codes (format line indicates 'ICD-10-CM Diagnosis Codes, 1 = Description. , 1 = All other codes')

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization / Verify Coverage

Prior authorization may be required for CPT 93660 when the medical necessity criteria in this policy are met. Verify prior authorization requirements and coverage for the member's specific plan, especially after this policy was revised (effective 2024-12-15).

Check prior authorization with the payer after policy revisions — plan benefits and prior authorization requirements may differ by product/line of business and over time.

Documentation Required

Initial Evaluation and Noninvasive Testing

Initial evaluation of syncope should include a complete history and physical examination, supine and upright blood pressure measurement, and a 12‑lead ECG. Additional noninvasive testing (as clinically indicated) may include echocardiography, exercise tolerance testing, Holter or loop-event monitoring, and carotid sinus massage. Tilt table testing is considered when the diagnosis remains uncertain after these evaluations.

Document history and physical exam findings, supine and upright blood pressures, and results of a 12‑lead ECG prior to tilt table testing.

Background

Syncope is a transient loss of consciousness most often caused by systemic hypotension. Common etiologies include reflex-mediated syncope (vasovagal) and orthostatic hypotension; cardiac causes such as arrhythmias or structural heart disease account for roughly 10–20% of episodes. Evaluation begins with a focused history, physical exam, measurement of supine and upright blood pressure, and a 12-lead ECG; additional testing, including tilt table testing, is reserved for selected patients when the diagnosis remains unclear or when results would influence management.

Definitions

Postural orthostatic tachycardia syndrome (POTS) — definition and diagnostic criteria

DefinitionA multisystem disorder of the autonomic nervous system characterized by symptoms of orthostatic intolerance for >6 months plus a heart rate increase >30 beats per minute within 10 minutes of standing (≥40 bpm in ages 12–19) or >120 bpm within 10 minutes, in the absence of orthostatic hypotension and other causes of tachycardia.

Required exclusions for diagnosisOccurs in the absence of prolonged bed rest and medications that impair autonomic regulation (e.g., diuretics, vasodilators, sympatholytics, certain antidepressants) and other causes of tachycardia (e.g., dehydration, anemia, hyperthyroidism).

Typical symptomsOrthostatic symptoms brought on by standing and relieved by sitting: lightheadedness, palpitations, fading vision, presyncope, difficulty concentrating, shortness of breath, tremulousness, chest discomfort, headache, mental clouding, nausea.

Diagnostic heart rate thresholdsHeart rate increase >30 bpm over baseline within 10 minutes of standing (≥40 bpm for ages 12–19) or absolute heart rate >120 bpm within 10 minutes.

Clinical note