CurrentCignaPolicy 0523

Transthoracic Echocardiography in Children

Cigna coverage policy governing initial outpatient non-stress transthoracic echocardiography for individuals under age 18, specifying medically necessary and not covered indications.

Policy Summary

PayerCigna

PolicyTransthoracic Echocardiography in Children

Policy CodePolicy 0523

Change TypeAdded/clarified guidance (HCM, minor wording edits)

Effective DateFeb 15, 2026

Next Review DateFeb 15, 2027

Key ActionDocument clinical indication and supporting diagnosis codes when submitting TTE and obtain prior authorization per plan when required.

SourceLink

POLICY UPDATE CHANGES

Removed redundant sentence in policy statement related to HCM.

Added policy statement for hypertrophic cardiomyopathy.

No policy statement changes during focused review.

<18Applies to

103AUC indications

53/28/32A/M/R counts

9Included CPT codes

≈120+ICD-10 codes in excerpt

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medically Necessary and Not Covered Indications

Initial outpatient TTE in an individual under age 18 — Additional indications

ALL of the following

Known channelopathy
Genotype positive for cardiomyopathy
Abnormal chest X-ray findings suggestive of cardiovascular disease
Abnormal ECG without symptoms
Desaturation based on pulse oximetry
Previously normal echocardiogram with a change in cardiovascular status and/or a new family history suggestive of heritable heart disease
Chromosomal abnormality known to be associated with cardiovascular disease
Chromosomal abnormality with undefined risk for cardiovascular disease
Consider specialist input when risk is uncertain
Positive blood cultures suggestive of infective endocarditis
Abnormal cardiac biomarkers
Abnormal barium swallow or bronchoscopy suggesting vascular ring
Abnormal cardiac finding on fetal echocardiogram or suspected cardiovascular abnormality on fetal echocardiogram
Maternal infection during pregnancy or delivery with potential fetal/neonatal cardiac sequelae
Maternal diabetes with no prior fetal echocardiogram or maternal diabetes with a normal fetal echocardiogram
Maternal phenylketonuria
Maternal autoimmune disorder
Maternal teratogen exposure
Individual taking FINTEPLA® (fenfluramine) for an FDA-approved indication (e.g., Dravet syndrome)
Pre-operative evaluation of cardiac structure and function prior to noncardiac solid organ transplantation
Monitoring for rejection in a cardiac transplant recipient
Cardiac structure and function evaluation in a potential heart donor
Initial evaluation prior to exposure to medications/radiation that could result in cardiotoxicity/heart failure
Re-evaluation (<1 year) in a patient previously or currently undergoing therapy with potentially cardiotoxic agents
Periodic re-evaluation in a patient undergoing therapy with cardiotoxic agents and worsening symptoms
Suspected cardiac mass
Chest mass or concern for any impingement of structure on the heart
Signs and symptoms of endocarditis in the absence of blood culture data or a negative blood culture
Unexplained fever without other evidence for cardiovascular or systemic involvement
Central cyanosis
Multisystem Inflammatory Syndrome (MIS) associated with SARS-CoV-2 (COVID-19) infection
Desire for preparticipation assessment of an asymptomatic athlete with ≥1 of the following: abnormal examination, abnormal ECG, or family history of inheritable heart disease associated with sudden death
See sports screening guidance and AHA recommendations
Cancer patients prior to, during, or following chemotherapy (also considered: cancer without chemotherapy when clinically indicated)
Sickle cell disease and other hemoglobinopathies
Connective tissue disorder such as Marfan, Loeys Dietz, and other aortopathy syndromes, or suspected connective tissue disorder
Clinically suspected syndrome or extracardiac congenital anomaly known to be associated with congenital heart disease
Human immunodeficiency virus infection
Suspected or confirmed Kawasaki disease
Suspected or confirmed Takayasu arteritis
Suspected or confirmed acute rheumatic fever
Systemic lupus erythematosus and autoimmune disorders
Muscular dystrophy
Systemic hypertension
Renal failure
Obesity with obstructive sleep apnea or obesity with other cardiovascular risk factors
Stroke
Suspected pulmonary hypertension
Hepatic disorders when associated with cardiovascular concern
Failure to thrive
Storage diseases, mitochondrial and metabolic disorders
Abnormalities of visceral or cardiac situs
Family history of unexplained sudden death before the age of 50 years, non-ischemic dilated cardiomyopathy, other cardiomyopathies, hypertrophic cardiomyopathy, or other genetic disorders at high risk for cardiovascular involvement
Family history of Marfan or Loeys Dietz syndrome or other connective tissue disorder with cardiovascular risk
Family history of congenital left-sided heart lesion or other congenital heart disease
Family history of idiopathic or heritable pulmonary arterial hypertension
Previously normal echocardiogram with a change in cardiovascular status and/or a new family history suggestive of heritable heart disease
Abnormal ECG without symptoms
Desaturation based on pulse oximetry

title":"Additional indications","type":"criteria_group"}],

CPT, HCPCS, and ICD-10 Codes and Status

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 or 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).
93356	Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging).

Not Covered CPT CodesCPTNot Covered

All other codes

Not covered or reimbursable unless specified as covered above.

Covered HCPCS Codes (contrast TTE)HCPCSCovered

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 Diagnosis Codes (selected ranges)ICD-10Covered

A01.02	Typhoid fever with heart involvement.
A02.1	Salmonella sepsis.
A18.84	Tuberculosis of heart.
A22.7	Anthrax sepsis.
A26.7	Erysipelothrix sepsis.
A32.7	Listerial sepsis.
A32.82	Listerial endocarditis.
A36.81	Diphtheritic cardiomyopathy.
A38.0-A38.9	Scarlet fever.
A39.50-A39.53	Meningococcal heart disease.

1–10 of 21

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Covered ICD-10 Diagnosis Codes (oncology and neoplasms)ICD-10Covered

C00.0-C14.8	Malignant neoplasm of lip, oral cavity and pharynx.
C15.3-C26.9	Malignant neoplasm of digestive organs.
C30.0-C39.9	Malignant neoplasms of respiratory and intrathoracic organs.
C40.00-C41.9	Malignant neoplasms of bone and articular cartilage.
C43.0-	Melanoma and other malignant neoplasms of skin.
C45.0-	Malignant neoplasms of mesothelial and soft tissue.
C50.011-	Malignant neoplasm of breast.
C50.921-C50.922	Malignant neoplasm of breast of unspecified site, male.
C50.A0-C50.A2	Malignant inflammatory neoplasm of breast.
C51.0-C58	Malignant neoplasms of female genital organs.

1–10 of 18

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Covered ICD-10 Diagnosis Codes (neoplasms - benign, in situ, uncertain)ICD-10Covered

D00.00-D09.9	In situ neoplasms.
D15.1	Benign neoplasm of heart.
D3A.00-D3A.8	Benign neuroendocrine tumors.
D37.01-D48.9	Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes.
D49.0-D49.9	Neoplasms of unspecified behavior.

Covered ICD-10 Diagnosis Codes (hematologic and coagulation)ICD-10Covered

D56.0-D56.9	Thalassemia.
D57.00-D57.819	Sickle cell disorders.
D58.2	Other hemoglobinopathies.
D65	Disseminated intravascular coagulation [defibrination syndrome].
D66	Hereditary factor VIII deficiency.
D67	Hereditary factor IX deficiency.
D68.00-D68.9	Other coagulation defects.
D69.0-D69.9	Purpura and other hemorrhagic conditions.

Covered ICD-10 Diagnosis Codes (immunodeficiency and metabolic)ICD-10Covered

D80.0-D80.5	Hereditary and nonfamilial hypogammaglobulinemia; selective IgA/IgG subclass deficiencies.
E70.0-E70.89	Disorders of aromatic amino-acid metabolism and related conditions.
E70.9	Disorder of aromatic amino-acid metabolism, unspecified.
E71.40-E71.448	Disorders of carnitine metabolism.
E72.52	Trimethylaminuria.
E72.530-E72.539	Primary Hyperoxaluria.
E72.540-E72.549	Secondary and dietary hyperoxaluria.
E73.0-E73.9	Lactose intolerance and related disorders.
E74.00-E74.9	Other disorders of carbohydrate metabolism.

Covered ICD-10 Diagnosis Codes (neurology, connective tissue, musculoskeletal)ICD-10Covered

G06.0-G06.1	Intracranial and intraspinal abscess and granuloma.
G40.811-G40.814	Lennox-Gastaut syndrome.
G40.833-G40.834	Dravet syndrome.
G40.841-G40.844	KCNQ2-related epilepsy.
G71.00-G71.29	Muscular dystrophies and congenital myopathies.
G90.1	Familial dysautonomia [Riley-Day].
G90.A	Postural orthostatic tachycardia syndrome [POTS].
M30.0-M35.9	Polyarteritis nodosa, necrotizing vasculopathies, systemic lupus, dermatomyositis, systemic sclerosis, Sjogren and related connective tissue disorders.
M36.0-M43.9	Dermatomyositis in neoplastic disease; systemic disorders of connective tissue; deforming dorsopathies and kyphosis/scoliosis ranges.
M96.2-M96.5	Postradiation/postlaminectomy/postsurgical kyphosis/scoliosis.

Covered ICD-10 Diagnosis Codes (cardiovascular, respiratory, hepatic, renal, obstetric, perinatal)ICD-10Covered

I01.0-I09.9	Rheumatic fever with heart involvement and chronic rheumatic heart diseases.
I10-I16.9	Hypertensive diseases.
I20.0-I25.9	Ischemic heart diseases.
I26.01-I28.9	Pulmonary heart disease and diseases of pulmonary circulation.
I30.0-I52	Other forms of heart disease including non-ischemic myocardial injury.
I63.00-I63.9	Cerebral infarction.
I66.01-I66.9	Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction.
I71.00-I71.9	Aortic aneurysm and dissection.
I75.011-I75.023	Atheroembolism of upper and lower extremities (specific ranges).
I75.81-I75.89	Atheroembolism of kidney and other sites.

1–10 of 27

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Covered ICD-10 Diagnosis Codes (congenital, chromosomal, and structural)ICD-10Covered

Q00.0-Q99.9	Congenital malformations, deformations, and chromosomal abnormalities (full Q00-Q99 range).
Q20.0-Q28.9	Congenital malformations of the circulatory system.
Q30.0-Q34.9	Congenital malformations of the respiratory system.
Q44.0-	Congenital malformations of gallbladder, bile ducts and liver.
Q67.6-Q79.69	Pectus deformities, congenital diaphragmatic hernia, Ehlers-Danlos syndromes, rib/sternum/bony thorax malformations.
Q85.00-Q86.8	Phakomatoses and congenital malformation syndromes due to known exogenous causes.
Q87.11-Q89.9	Congenital malformation syndromes associated with short stature and other congenital malformations.
Q90.0-Q99.9	Chromosomal abnormalities and related conditions.

Covered ICD-10 Diagnosis Codes (signs, symptoms, findings)ICD-10Covered

R00.0-R99.9	Abnormal findings and signs/symptoms of circulatory, respiratory and general systems (full R00-R99 range).
R91.1-R94.39	Abnormal findings on diagnostic imaging of lung, heart and other cardiovascular function studies.
R07.2-R07.9	Precordial pain, chest pain and related chest symptoms.
R06.00-R06.4	Dyspnea, orthopnea, shortness of breath, acute respiratory distress and hyperventilation.
R55	Syncope and collapse.
R65.10-R65.21	Symptoms/signs associated with systemic inflammation and infection (sepsis syndromes).

Covered ICD-10 Diagnosis Codes (trauma, injury, procedural complications, poisoning)ICD-10Covered

S21.101A-S29.029D	Open wounds and related thorax injuries (front/back/unspecified) with ranges.
S25.00XA-S38.1XXA	Injury of thoracic vessels, heart, lung and related intrathoracic injuries.
S27.301A-S27.9XXS	Other and unspecified injury of lung and intrathoracic organs.
S28.0XXA-S77.22XS	Crushed chest, traumatic amputation of thorax, and related thoracic traumatic injuries.
T07.XXXA-T14.8XXS	Unspecified multiple injuries and other injury of unspecified body region.
S27.499S	Injury of bronchus.
S27.50XA-S27.69XS	Injury of thoracic trachea, pleura ranges.
S27.802A-S27.899S	Injury of other specified intrathoracic organs.
S27.9XXA-S27.9XXS	Injury of unspecified intrathoracic organ.
S29.021A-S29.029D	Laceration of muscle and tendon of thorax front/unspecified ranges.

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Covered ICD-10 Diagnosis Codes (complications, device/prosthesis, transplant, aftercare, history)ICD-10Covered

T81.10XA-T81.595S	Postprocedural shock, infection, and other complications including foreign body left after heart catheterization ranges.
T81.718A-T81.72XS	Complications of other/unspecified artery or vein following a procedure.
T82.01XA-T82.9XXS	Complications of cardiac and vascular prosthetic devices, implants and grafts.
T84.50XD-T84.59XS	Infection and inflammatory reaction due to internal joint prosthesis.
T85.730A-T85.738S	Infection and inflammatory reaction due to nervous system devices.
T86.20-	Complications of heart transplant.
T86.30-	Complications of heart-lung transplant.
T88.2XXA-T88.6XXS	Shock due to anesthesia; anaphylactic reaction due to adverse effect of properly administered drug.
Z01.810-Z01.818	Encounters for preprocedural cardiovascular, respiratory, laboratory and other examinations.
Z08-Z09	Encounters for follow-up examinations after completed treatment for malignant neoplasm and other conditions.

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Referenced Coverage Policy Codesmixed

0510	Refer to Cigna Coverage Policy 0510 Transthoracic Echocardiography in Adults.
0523	This policy number.

Not Covered ICD-10-CM DiagnosesICD-10Not Covered

All other codes

ICD-10-CM diagnosis codes not specifically listed as covered above are not covered or reimbursable under this policy.

Key Clinical Notes

HCM LVOT gradientResting peak LVOT gradient <50 mm Hg (provocative recommended)

Provocable LVOT gradient>=50 mm Hg threshold

Policy criteriaMust meet specific applicable policy statements referenced elsewhere

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization may be required — benefit-plan and utilization review

Coverage determinations depend on the terms of the applicable benefit plan; where required by the plan or delegated vendor, utilization review or prior authorization processes may apply. In the absence of a controlling benefit provision, benefits are determined by the plan document and claims submitted without covered codes under the applicable Coverage Policy will be denied as not covered.

Prior Authorization

Prior authorization for listed TTE CPT/HCPCS codes

Prior authorization/coverage applies to the listed transthoracic echocardiography CPT codes (93303, 93304, 93306–93308, 93319, 93320–93321, 93325) and contrast HCPCS codes (C8921–C8924, C8929) when the service is performed for indications that meet the policy's medical necessity criteria.

Prior Authorization

Prior authorization contingent on meeting policy criteria

Prior authorization/medical necessity review is required to establish that the listed diagnoses meet the applicable policy statements; diagnoses alone are not sufficient without documentation that the policy criteria are met.

Scope and Policy Context

Scope: this Cigna policy covers non‑stress transthoracic echocardiography (TTE) for the pediatric population (individuals under age 18). It distinguishes indications considered medically necessary (for example, palpitations with abnormal ECG, syncope with abnormal ECG or exertional features, suspected cardiomyopathy, transplant monitoring, MIS‑C, and surveillance of congenital heart disease per AUC tables) from specific scenarios that are not covered (for example, isolated benign palpitations with normal ECG, probable vasovagal syncope, routine pre‑ADHD screening, and previously normal TTE with no change in status).

Providers should document the clinical findings linking the patient’s presentation to the applicable policy statements and submit the appropriate CPT and ICD‑10 codes; services and codes are considered medically necessary only when the policy criteria are met and supported in the medical record.

Pediatric population definition

DefinitionIndividuals under age 18 (pediatric population) to whom this TTE coverage policy applies

ScopeApplies to non-stress transthoracic echocardiography in pediatric patients

Age cutoffUnder 18 years at time of service

Glossary and Abbreviations

Abnormal imaging findings code (R93.1)

Example ICD-10 codeR93.1 — Abnormal findings on diagnostic imaging of heart and coronary circulation

ContextListed as a diagnosis that may support medical necessity when applicable policy criteria are met

Billing noteUse associated clinical documentation to justify TTE when R93.1 is billed

Abnormal lung imaging code range (R91.1-)

Example code rangeR91.1- — Abnormal findings on diagnostic imaging of lung (range indicated in policy)

ImplicationThese codes are included among diagnosis codes that may support TTE when policy criteria are met

Policy Changes and Effective Dates

2026-02-15annual_reviewLatest

Removed a redundant sentence in the policy statement related to hypertrophic cardiomyopathy (no change to intent of coverage).

2025-02-15annual_review

Added a policy statement for hypertrophic cardiomyopathy.

Policy Summary

PayerCigna

PolicyTransthoracic Echocardiography in Children

Policy CodePolicy 0523

Change TypeAdded/clarified guidance (HCM, minor wording edits)

Effective DateFeb 15, 2026

Next Review DateFeb 15, 2027

Key ActionDocument clinical indication and supporting diagnosis codes when submitting TTE and obtain prior authorization per plan when required.

SourceLink

On This Page

Prior Authorization

Prior authorization applies when services are billed with listed ICD-10 codes

When billing for services tied to the listed ICD-10 codes, prior authorization requirements in the applicable policy statements apply and must be met to consider the service medically necessary.

Prior Authorization

Diagnosis-code-linked medical necessity — prior auth required

Prior authorization/medical necessity review is required per the applicable policy statements; services are considered medically necessary only when the criteria in those statements are met and the listed ICD-10 codes apply.

Documentation Required

Include preprocedural/aftercare encounter Z‑codes in authorization documentation

Preprocedural encounter Z-codes (Z01.810, Z01.811, Z01.812, Z01.818) and related aftercare/encounter codes (Z48.21, Z48.24, Z48.280, Z48.812) are listed as medically necessary when applicable and should be included in documentation for procedures that require prior authorization.

Prior Authorization

Prior authorization/coverage condition for CPT 93356

CPT 93356 (myocardial strain imaging) is considered medically necessary only when the primary TTE (93303, 93304, 93306, 93307, 93308) on the same date is medically necessary and the study is billed with one or more of the listed ICD-10 diagnoses referenced in the policy.

Prior Authorization

Prior authorization expectation by AUC appropriateness

Prior authorization is more likely to be required or favorably reviewed when the indication aligns with 'Appropriate' AUC categories (e.g., syncope with abnormal ECG, exertional chest pain) and less likely when the indication is 'Rarely Appropriate.'

Note

Align imaging orders with 2020 AUC ratings for CHD

Orders for imaging in congenital heart disease should align with the 2020 Appropriate Use Criteria (AUC) ratings (A/M/R); document the rated indication and clinical context to support medical necessity during authorization review.

Note

Prior authorization not specified in AUC timing tables

This section provides recommended timing and surveillance intervals by diagnosis (AUC tables) but does not specify explicit prior authorization rules in those table entries.

Note

TTE indication and surveillance guidance is informational (not authorization rules)

The indication- and interval-based guidance for TTE (disease-specific surveillance tables) is informational for clinical timing and does not, by itself, state explicit payer prior authorization requirements.

Note

Authorization cross-reference to Policy 0510 for myocardial strain imaging

This section describes intervals and indications for TTE (including HCM and CHD surveillance) but does not create separate payer authorization requirements beyond the policy statements elsewhere.

Step Therapy

Step therapy — no sequencing required; CPT 93356 conditional on primary TTE

No step therapy is specified; myocardial strain imaging (93356) is allowed only when the primary TTE is medically necessary and additional specified indications (cardiotoxicity monitoring or HCM evaluation) are met.

Step Therapy

Consider alternatives before imaging for 'May Be Appropriate' scenarios

For indications rated 'May Be Appropriate,' consider targeted alternative evaluation or watchful waiting (for example ECG, reassessment of history, infection or systemic workup) before ordering echocardiography when clinically reasonable.

Obtain ECG or repeat ECG if not recent.
Reassess history and perform targeted infectious/systemic evaluation when relevant.

Billing Rule

Use appropriate codes and include covered diagnosis/procedure codes — billing requirement

When billing, providers must use the most appropriate CPT/HCPCS and ICD-10 codes as of the submission date and submit services with covered diagnosis and procedure codes under the applicable Coverage Policy; claims lacking covered codes will be denied as not covered.

Documentation Required

Document indication and submit matching CPT/HCPCS codes

Document the clinical indication that matches the applicable policy criteria and submit the appropriate CPT (93303–93308, 93319, 93320–93321, 93325) and HCPCS contrast codes (C8921–C8924, C8929) when medically necessary.

Documentation Required

Document that applicable policy criteria are met for listed ICD-10 diagnoses

Providers must document that the specific criteria in the applicable policy statements are met for the listed ICD-10-CM diagnoses to be considered medically necessary; failure to document those criteria may result in denial.

Documentation Required

Supporting documentation requirement — show criteria met

Documentation must demonstrate that the patient meets the applicable policy statements referenced above for any listed ICD-10 code to be considered medically necessary; include relevant clinical findings, test results, and timing.

Documentation Required

Document diagnosis linkage to T43–T46 (and other listed codes)

Clinical documentation must support that the patient's condition corresponds to one of the listed ICD-10 codes in the T43–T46 ranges (or other enumerated codes) and that the applicable policy criteria are met.

Billing Rule

Include listed Z‑codes for preprocedural and aftercare encounters

Z-codes for preprocedural evaluation and aftercare (Z01.810–Z01.818; Z48.21, Z48.24, Z48.280, Z48.812) are listed and may be required to document preprocedural evaluation and postprocedural follow-up when applicable.

Billing Rule

Diagnosis linkage requirement when billing CPT 93356

Providers must bill CPT 93356 with one or more of the listed ICD-10 diagnoses enumerated in the policy for the code to be considered medically necessary; submit supporting clinical documentation per the policy.

Documentation Required

Document clinical features that support 'Appropriate' indications

When ordering or documenting services aligned with 'Appropriate' AUC indications, include clinical features (abnormal ECG, exertional symptoms, signs of CHF, positive blood cultures, abnormal biomarkers, genotype positive for cardiomyopathy, systemic disease exposures) that justify the imaging.

Documentation Required

HCM management — required documentation and surveillance interval

For hypertrophic cardiomyopathy management, document clinical status, events, and TTE findings; repeat TTE every 1–2 years for stable pediatric patients and sooner with change in clinical status per AHA/ACC guidance.

Repeat TTE every 1–2 years in children with HCM if stable.
Obtain repeat TTE sooner with change in clinical status or new events.

Documentation Required

Required documentation for cardiac risk assessment and stimulant/nonstimulant screening

Document a detailed personal and family cardiac history, relevant physical exam findings, and the results of ECG (when performed) or specialist referrals when screening or evaluating children for SCA/SCD risk or before initiating stimulant/nonstimulant medications.

Denial Risk

Claims lacking covered diagnosis/procedure codes will be denied

Claims submitted without a covered diagnosis and/or appropriate procedure code under this Coverage Policy will be denied as not covered; ensure claim coding aligns with the enumerated covered codes and documented medical necessity.

Denial Risk

Denial risk — previously normal TTE with no status change

Initial outpatient TTE is not covered when a previously normal echocardiogram shows no change in cardiovascular status or family history, or for elevated ASO titers without suspicion for rheumatic fever; submitting such claims risks denial.

Denial Risk

Denial risk — additional not-covered outpatient TTE conditions

Initial outpatient TTE is not covered for conditions such as obesity without other cardiovascular risk factors, diabetes, lipid disorders, certain neurologic/psychiatric or nonspecific GI disorders, and several listed family-history scenarios; billing for these alone may be denied.

Denial Risk

Medical necessity contingent on documented policy criteria — denial risk

Claims with diagnosis codes listed are considered medically necessary only when the criteria in the applicable policy statements are met; absence of those documented criteria may trigger denial of coverage.

Denial Risk

Services covered only if policy criteria are met for listed ICD-10 codes

Services associated with listed ICD-10 codes are considered medically necessary only when the criteria in the applicable policy statements are met; billing those codes without meeting the policy criteria may lead to denial.

Denial Risk

Missing listed diagnosis codes (T43–T46) may trigger denial

Claims lacking an applicable diagnosis code from the listed ICD-10 T43–T46 series when those codes are required by the policy could be denied; include the appropriate listed code(s) on the claim.

Denial Risk

Unlisted or unsupported codes risk Not Covered determination

Use of CPT or ICD-10 codes outside those listed as covered/medically necessary may result in a determination of Not Covered or Reimbursable; do not submit unsupported codes expecting coverage.

Denial Risk

Denial risk when indication is 'Rarely Appropriate'

Requests for echocardiography are at greater risk for denial when the indication is listed as 'Rarely Appropriate' (examples: isolated benign murmur with no symptoms, chest pain with normal ECG and benign history, syncope without ECG or benign history, isolated fatigue with normal ECG and benign history).

Denial Risk

Routine surveillance for PFO is 'Rarely Appropriate' — denial risk

Routine surveillance TTE for asymptomatic patients with a patent foramen ovale (PFO) is rated 'Rarely Appropriate' and may result in denial if submitted for routine surveillance without other supporting indications.

Denial Risk

Document history/ECG/referral before stimulant/nonstimulant use — denial risk if omitted

When assessing stimulant or nonstimulant medication initiation and preparticipation screening, failure to obtain and document a detailed personal and family cardiac history, or to perform indicated further evaluation (ECG or pediatric cardiology referral) when risk factors exist, may lead to denial of coverage for subsequent cardiac testing if not documented.

Myocardial strain imaging definition

TechniqueSpeckle-tracking myocardial strain imaging — assessment of myocardial mechanics performed adjunctively with primary TTE

Use-case linkagePerformed in addition to a medically necessary primary TTE (CPT 93303/93304/93306/93307/93308) on same date

Primary indicationsUsed for cardiotoxicity monitoring (prior to, during, following exposure) or to evaluate hypertrophic cardiomyopathy

HCM surveillance definition

HCM baseline and follow-upBaseline assessment for suspected HCM and routine surveillance every 1–2 years in children without change in status

Post-intervention timingTTE within 3–6 months after septal reduction therapy (SRT) or alcohol septal ablation follow-up

Provocative testingIf resting LVOT gradient <50 mm Hg, perform TTE with provocative maneuvers; repeat sooner with change in clinical status

Considered Medically Necessary — definition

Considered Medically Necessary — meaningServices associated with the listed ICD-10-CM diagnoses will be covered when the applicable policy criteria are documented and met

Conditional natureListing of a diagnosis code alone does not establish coverage; applicable policy statements must be satisfied

Documentation expectationProvider must document clinical criteria that align with the referenced policy statements to support medical necessity

Clinical imaging findings should be documented when using R91.1- range codes to support TTE

T43–T46 ICD-10 series

Series definitionT43–T46 ICD-10 series — grouped codes covering poisoning and adverse effects by psychotropic, autonomic, systemic/hematologic, and cardiovascular agents

Included subcategoriesSubseries include antidepressants/psychotropics (T43), autonomic agents (T44), systemic/hematologic agents (T45), and cardiovascular agents (T46)

Claim requirementClaims using T-series codes are considered medically necessary only when applicable policy criteria are met

Poisoning and adverse effects of cardiovascular agents

Range definitionT46.x - T50.x series — poisoning and adverse effects of cardiovascular and related pharmacologic agents (policy references T46.x onward)

ExamplesIncludes codes for ACE inhibitors, antihypertensives, antihyperlipidemics, coronary vasodilators and other cardiovascular drugs

Usage noteThese codes are listed as allowable contexts when policy criteria are met

Encounter, aftercare, transplant/device status and history codes

Z-code groupEncounter, aftercare, transplant/device status and history codes (Z-codes) — e.g., Z01.810, Z48.21, Z94.1, Z95.0 among others listed

ExamplesZ01.810 (preprocedural cardiovascular exam); Z48.21 (aftercare following heart transplant); Z94.1 (heart transplant status); Z95.0 (presence of pacemaker)

Documentation roleThese Z-codes are acceptable billing contexts for certain covered myocardial strain or TTE services when policy criteria are met

Myocardial strain — definition

DefinitionMyocardial strain = deformation produced by applied force; percent change in myocardial length from relaxed to contractile state

Clinical interpretation caveatStrain values vary among methods, modalities and software versions — interpret in context

Primary useCommonly used to identify cancer therapy–related cardiac dysfunction

Myocardial strain imaging (speckle tracking) & CPT 93356

Definition and codeMyocardial strain imaging (speckle tracking) — speckle-tracking assessment of myocardial mechanics performed adjunctively with echocardiography; CPT 93356 is the listed code

Ordering constraintCPT 93356 is allowed only when a medically necessary primary TTE (93303/93304/93306/93307/93308) is performed on the same date and policy criteria are met

IndicationsPermitted for cardiotoxicity monitoring (prior to/during/after exposure) and for HCM evaluation; not covered for other indications

Appropriate — AUC category

AUC category — AppropriateA (Appropriate): median score 7–9; test is generally acceptable and reasonable for the indication (examples include syncope with abnormal ECG, exertional chest pain)

ExamplesSyncope with abnormal ECG, exertional syncope, pathologic murmur, suspected endocarditis — typically rated Appropriate

Decision supportOrders aligning with A-rated indications are more likely to be approved in utilization review

May Be Appropriate — AUC category

AUC category — May Be AppropriateM (May Be Appropriate): median score 4–6; test may be reasonable depending on additional clinical context

ExamplesUnexplained pre-syncope, chest pain with other symptoms but normal ECG, known channelopathy depending on context

Clinical actionConsider additional targeted evaluation (ECG, history reassessment) before imaging in M-rated scenarios

Rarely Appropriate — AUC category

AUC category — Rarely AppropriateR (Rarely Appropriate): median score 1–3; test is generally not indicated and not a reasonable approach for the indication

ExamplesIsolated benign murmurs without symptoms, chest pain with normal ECG and benign history, probable vasovagal syncope

Coverage implicationR-rated scenarios carry higher risk of denial if submitted without additional supporting findings

AUC ratings — definitions

AUC ratings definitionsA = Appropriate (median score 7-9); M = May be Appropriate (median score 4-6); R = Rarely Appropriate (median score 1-3)

InterpretationMedian score ranges determine category assignment used in policy tables and utilization decisions

ApplicationRatings are applied across pediatric initial TTE and CHD follow-up AUC tables referenced in the policy

TTE abbreviation definition

TTE abbreviationTTE = Transthoracic echocardiography (non-stress) — primary imaging modality referenced throughout policy

ContextUsed for surveillance, evaluation, pre-/post-procedural assessment, and diagnostic evaluation in pediatric patients

Contrast noteSome table entries rate TTE with contrast separately (not always rated) — see table specifics

Surveillance intervals — definition

DefinitionSurveillance intervals = specified follow-up timing (examples: 1–3 months, 6–12 months, 1–2 years, 3–5 years) based on age, lesion severity, and clinical context

ExamplesInfant surveillance may be 1–3 months; children with mild disease often 1–2 years; trivial lesions may be 3–5 years — see tables for lesion-specific intervals

Use in coverageSurveillance intervals in AUC tables guide when routine TTE is considered medically necessary

Routine surveillance — definition

Routine surveillance definitionScheduled echocardiographic follow-up in asymptomatic patients after repair or during longitudinal care; interval varies by lesion and severity

Postprocedural timingRoutine postprocedural TTE within 30 days is commonly recommended across many CHD entries

Coverage implicationRoutine surveillance is covered when the interval and lesion severity align with AUC table recommendations

Change in clinical status — definition

Trigger definitionChange in clinical status = new or worsening signs or symptoms prompting evaluation with TTE (e.g., new murmur, heart failure symptoms, syncope) — triggers earlier TTE

HCM exampleIn HCM, repeat TTE is recommended sooner than routine intervals when there is a change in clinical status or new event

CHD tablesMany lesion-specific tables list 'evaluation due to change in clinical status' as A-rated indications

Preparticipation cardiovascular screening — definition

DefinitionPreparticipation cardiovascular screening = targeted personal/family history and physical exam for athletes; routine ECG/TTE not recommended for mandatory universal screening; use ECG/TTE when screening raises suspicion

Guideline contextAHA/AAP guidance recommends detailed evaluation and ECG interpretation by trained clinicians when concerns identified

Coverage implicationPreparticipation TTE may be covered when screening identifies concerning findings per policy criteria

Myocardial Strain Imaging — cross-reference

Cross-referenceMyocardial Strain Imaging — see related Cigna adult TTE policy 0510 for additional guidance and coding context

Coding noteCPT 93356 (myocardial strain) is addressed in this pediatric policy but cross-referenced to adult policy 0510 for broader context

Indication alignmentPediatric myocardial strain imaging remains conditional on primary TTE medical necessity and specified indications (cardiotoxicity, HCM)