CurrentEvolentPolicy N/A

Transthoracic Echocardiography (TTE) Coverage

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This tip sheet summarizes Evolent medical-necessity and appropriateness considerations for transthoracic echocardiograms, primarily for adult cardiovascular cases and selected post-COVID-19 evaluations. It is intended to assist providers and does not replace the applicable Evolent clinical guidelines used for case review.

Policy Summary

PayerEvolent

PolicyTransthoracic Echocardiography (TTE) Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide prior TTE reports or physician notes documenting prior findings, with office notes dated within six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 weeksChemotherapy monitoring interval

6 monthsAortic aneurysm initial follow-up

4.5 cmAortic aneurysm surveillance threshold

3 yearsBicuspid valve surveillance

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CurrentEvolentPolicy N/A

Transthoracic Echocardiography (TTE) Coverage

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Policy Summary

PayerEvolent

PolicyTransthoracic Echocardiography (TTE) Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide prior TTE reports or physician notes documenting prior findings, with office notes dated within six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 weeksChemotherapy monitoring interval

6 monthsAortic aneurysm initial follow-up

4.5 cmAortic aneurysm surveillance threshold

3 yearsBicuspid valve surveillance

Post-COVID-19 interval

0.5 cm/yearAortic aneurysm growth threshold

Medical Necessity and Appropriateness Criteria

Adult cardiovascular review cases

TTE may be approvable for adult cardiovascular cases when the applicable clinical indication and documentation requirements are met.

General adult cardiovascular requirements

Supported indication
- Palpitations: Signs or symptoms of cardiovascular disease are present, such as a significant murmur or an ECG suggesting a cardiac etiology, including ventricular arrhythmia or atrial fibrillation.
- Syncope is exercise-induced.
  Clearly documented vasovagal syncope or lightheadedness is not approvable.
- Murmur: The murmur is documented as pathologic, such as diastolic, holosystolic, or continuous, or there is reasonable suspicion of valvular or structural heart disease.
- Arrhythmia: Frequent PVCs, initial-diagnosis paroxysmal or sustained atrial fibrillation, or ventricular bigeminy, trigeminy, or NSVT is documented on ECG or Holter monitoring.Frequent PVCs: >30 per hour on remote monitoring or ≥1 PVC on a 12-lead ECG
- Hypertension: There is suspicion of hypertensive heart disease, such as LVH on ECG.
  Repeated studies without new symptoms are not approvable.
- Pulmonary hypertension: A physician clearly documents suspicion of pulmonary hypertension.
  Yearly TTE is not allowable for mild pulmonary hypertension without new symptoms; TTE may be performed as needed for primary pulmonary hypertension to guide therapy.
- Heart failure: The patient has symptoms or TTE is needed to guide therapy in documented systolic or diastolic heart failure.
  This does not include the initial period when device management is being considered.
- Edema with additional CHF findings: Edema is accompanied by other signs of congestive heart failure, such as shortness of breath, rales on lung examination, or an S3 gallop.
- Cardiotoxic chemotherapy: TTE is being used for baseline, during-treatment, or post-treatment evaluation of cardiotoxic chemotherapy.Usually no more than once every 6 weeks unless there has been a decrease in ejection fraction
  Use a MUGA scan or cardiac MRI if TTE is inadequate.
- Solid-organ transplant: TTE is requested for preoperative evaluation of a solid-organ transplant.Yearly preoperative evaluation
- Aortic root or thoracic aortic aneurysm disease: TTE is used for initial or surveillance assessment of thoracic aortic aneurysm or related aortic-root disease according to size, growth, and risk factors.Initial follow-up at 6 months; annual if stable <4.5 cm; twice yearly if >4.5 cm or growth >0.5 cm/year
  The surveillance intervals also apply to relevant connective-tissue or genetic conditions. Additional twice-yearly imaging is allowed for bicuspid aortic valve with thoracic aneurysm and a first-degree family history of dissection.

Valvular and prosthetic valve surveillance

Surveillance TTE is allowed at the stated intervals when the relevant valve or aortic condition is documented.

Valvular or prosthetic valve surveillance

Bicuspid aortic valve: Routine surveillance of a bicuspid aortic valve is requested.Every 3 years
Allowed regardless of whether stenosis is present.
Severe aortic stenosis: The patient has severe aortic stenosis without symptoms.Every 6 months
Moderate aortic stenosis: The patient has moderate aortic stenosis.Yearly

Post-COVID-19 evaluation

Post-COVID-19 TTE is targeted to patients with qualifying new symptoms or high-risk prior hospitalization findings.

Post-COVID-19 qualifying evaluation: After COVID-19 infection, the patient has new-onset heart failure, unexplained cardiac arrhythmia, chest pain, shortness of breath, ECG changes, unusual fatigue that prevents performance of prior activities of daily living, prior hospitalization with positive troponins, or prior hospitalization requiring mechanical ventilation.

When more than 6 weeks have elapsed since a positive test, the listed new symptoms and prior hospitalization findings support TTE. When less than 6 weeks have elapsed, no further testing is needed if TTE has already been performed and symptoms have not worsened.

TTE is not approvable for isolated sinus bradycardia or for atrial premature contractions without atrial fibrillation or supraventricular tachycardia. It is also not approvable for known coronary artery disease when prior myocardial perfusion imaging or left-heart catheterization showed normal left ventricular ejection fraction and there are no new symptoms, or for trace valvular regurgitation without new symptoms.

TTE is not approvable for chest pain when an exercise treadmill test, myocardial perfusion imaging, or stress echocardiogram is also being ordered to evaluate the symptoms. Clearly documented vasovagal syncope or lightheadedness is not an indication; exercise-induced syncope may be approvable. TTE is also not indicated for edema alone without additional congestive heart-failure findings, routine yearly heart-failure surveillance without symptoms or a need to guide therapy, or yearly surveillance of mild pulmonary hypertension without new symptoms.

After COVID-19 infection, no further TTE testing is needed when more than 6 weeks have elapsed since a positive test and there are no new symptoms. When less than 6 weeks have elapsed, no further testing is needed if a TTE has already been performed and symptoms have not worsened.

Repeated hypertension-related TTE studies without new symptoms are not approvable. Requests should document suspected hypertensive heart disease, such as left ventricular hypertrophy on an ECG.

Covered TTE Indications

Adult cardiovascular evaluation

TTE is covered for adult cardiovascular evaluation when at least one qualifying indication is documented.

Adult cardiovascular indication: TTE is requested for qualifying palpitations, exercise-induced syncope, a pathologic murmur or suspected structural disease, qualifying arrhythmia, suspected hypertensive heart disease, symptomatic or therapy-guided heart failure, pulmonary hypertension, or edema with additional congestive-heart-failure findings.

Provide prior TTE reports or physician notes documenting findings, and office notes dated within six months.

Arrhythmia evaluation

TTE is covered when a qualifying arrhythmia is documented.

Arrhythmia indication: Frequent PVCs, initial diagnosis of paroxysmal or sustained atrial fibrillation, or ventricular bigeminy, trigeminy, or NSVT is documented on an ECG or Holter monitor.Frequent PVCs: >30 per hour on remote monitoring or ≥1 PVC on a 12-lead ECG

TTE Surveillance and Monitoring Intervals

Bicuspid aortic valve surveillance

ModalityTransthoracic echocardiography

Frequency limitEvery 3 years

Applicable conditionRoutine surveillance of a bicuspid aortic valve, regardless of whether stenosis is present

Severe aortic stenosis surveillance

ModalityTransthoracic echocardiography

Frequency limitEvery 6 months

Applicable conditionSevere aortic stenosis without symptoms

Clinical Thresholds and Coding Rules

Frequent PVC threshold

FindingFrequent premature ventricular contractions (PVCs)

Remote monitoring thresholdMore than 30 PVCs per hour

12-lead ECG thresholdAt least 1 PVC

Thoracic aortic aneurysm growth

ConditionThoracic aortic aneurysm

Growth thresholdGreater than 0.5 cm per year

Surveillance implicationBiannual (twice-yearly) follow-up can be performed

Documentation and Request Requirements

Documentation Required

Provide Prior Imaging and Current Notes

Submit prior transthoracic echocardiogram (TTE) reports or physician notes documenting the relevant findings. Office notes must be dated within six months of the request.

Prior TTE reports or physician notes documenting findings
Office notes dated within six months

Documentation Required

Document the Clinical Indication

Document the clinical indication supporting the TTE request, including the relevant symptom, sign, ECG finding, pathologic murmur characteristics, or reasonable suspicion of valvular or structural heart disease.

Symptoms or signs such as chest pain, palpitations, syncope, or other cardiovascular findings
ECG findings suggesting a cardiac etiology
Murmur characteristics or suspicion of valvular or structural heart disease

Policy Terms

Transthoracic echocardiography (TTE) evaluates structural heart disease and ventricular and valvular function. The policy supports targeted use when symptoms or abnormal cardiac findings warrant evaluation, and for selected surveillance and treatment-monitoring situations, including valvular disease, aortic disease, cardiotoxic chemotherapy, transplant evaluation, and selected post-COVID-19 manifestations.

CVR cases

PopulationAdults

Clinical contextCardiovascular review cases evaluated under the cardiovascular clinical review recommendations

Documentation contextPrior TTE reports or physician notes documenting findings are required, with office notes within six months

Frequent PVCs

FindingFrequent premature ventricular contractions (PVCs)

Non-Covered TTE Uses

The following uses are not covered or are not approvable: TTE for sinus bradycardia alone; atrial premature contractions without atrial fibrillation or supraventricular tachycardia; known coronary artery disease with normal prior left ventricular ejection fraction and no new symptoms; and trace valvular regurgitation without new symptoms.

Policy Summary

PayerEvolent

PolicyTransthoracic Echocardiography (TTE) Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide prior TTE reports or physician notes documenting prior findings, with office notes dated within six months.

SourceLink

On This Page

Moderate native valvular regurgitation: The patient has moderate native valvular regurgitation without symptoms.Yearly

Severe aortic or mitral regurgitation: The patient has severe aortic or mitral regurgitation without symptoms.Every 6 months

Mild valvular regurgitation: The patient has mild valvular regurgitation requiring follow-up.Every 3 years

Prosthetic heart valve: The patient has a prosthetic valve and is undergoing baseline assessment after valve replacement, routine follow-up, or follow-up more than 10 years after implantation.Baseline at 6 weeks to 3 months postoperatively; yearly after 10 years; every 3 years thereafter

If symptoms are present, testing may be performed as needed.

Valvular and prosthetic valve assessment

TTE is covered for documented valve disease or a prosthetic valve when the applicable surveillance interval or symptom requirement is met.

Valve indication: The patient has documented aortic stenosis, native valvular regurgitation, bicuspid aortic valve, or a prosthetic heart valve and meets the applicable surveillance interval or symptom requirement.Intervals range from every 6 months to every 3 years

Thoracic aortic aneurysm or aortic root surveillance

TTE is covered for initial or surveillance assessment of thoracic aortic or aortic-root disease when the applicable size, growth, and risk criteria are documented.

Aortic disease indication: TTE is requested for initial or surveillance imaging of a thoracic aortic aneurysm or related aortic-root disease, including selected patients with connective-tissue or genetic disease, bicuspid aortic valve, or a first-degree family history of aortic dissection.Initial follow-up at 6 months; annual if stable <4.5 cm; twice yearly if >4.5 cm or growth >0.5 cm/year

Chemotherapy-related cardiac monitoring

TTE is covered for cardiac monitoring associated with cardiotoxic chemotherapy.

Cardiotoxic chemotherapy: TTE is used at baseline, during, or after chemotherapy with cardiotoxic agents.Usually no more than once every 6 weeks unless there has been a decrease in ejection fraction

A MUGA scan or cardiac MRI may be used if TTE is inadequate.

Solid-organ transplant evaluation

TTE is covered for preoperative evaluation before solid-organ transplantation.

Solid-organ transplant evaluation: The patient is undergoing preoperative evaluation for a solid-organ transplant.Yearly preoperative TTE

Post-COVID-19 cardiac evaluation

TTE is covered for selected patients with new cardiac symptoms or findings after COVID-19 infection.

Post-COVID-19 indication: After COVID-19 infection, the patient has new-onset heart failure, unexplained cardiac arrhythmia, chest pain, shortness of breath, ECG changes, unusual fatigue that prevents performance of prior activities of daily living, prior hospitalization with positive troponins, or prior hospitalization requiring mechanical ventilation.More than 6 weeks since a positive COVID-19 test for the listed post-infection approval scenarios

If less than 6 weeks have elapsed and TTE has already been performed without worsening symptoms, no further testing is needed. In general, cardiac MRI should not be performed without first performing a TTE.

Moderate aortic stenosis surveillance

ModalityTransthoracic echocardiography

Frequency limitYearly

Applicable conditionModerate aortic stenosis

Moderate native valvular regurgitation surveillance

ModalityTransthoracic echocardiography

Frequency limitYearly

Applicable conditionModerate native valvular regurgitation without symptoms

Severe valvular regurgitation surveillance

ModalityTransthoracic echocardiography

Frequency limitEvery 6 months

Applicable conditionSevere aortic or mitral regurgitation without symptoms

Mild valvular regurgitation surveillance

ModalityTransthoracic echocardiography

Frequency limitEvery 3 years

Applicable conditionFollow-up of mild valvular regurgitation

Prosthetic heart valve surveillance

ModalityTransthoracic echocardiography

After implantationYearly after 10 years

Routine follow-up thereafterEvery 3 years

Cardiotoxic chemotherapy monitoring

ModalityTransthoracic echocardiography

Usual maximum frequencyNot more than once every 6 weeks

ExceptionMore frequent testing may be performed if ejection fraction has decreased

Thoracic aortic aneurysm surveillance

Initial follow-up6 months after diagnosis of thoracic aortic aneurysm

Annual surveillanceAllowed when the aneurysm is stable and less than 4.5 cm

Twice-yearly surveillanceAllowed when the aneurysm is greater than 4.5 cm or growth is greater than 0.5 cm per year

Stable thoracic aortic aneurysm

ConditionStable thoracic aortic aneurysm

Size thresholdLess than 4.5 cm

Surveillance intervalAnnual imaging is allowed

Cardiotoxic chemotherapy monitoring

Monitoring purposeBaseline, during, and after chemotherapy with cardiotoxic agents

Usual maximum frequencyNot more than once every 6 weeks

ExceptionThe six-week limit does not apply when ejection fraction has decreased

Post-COVID-19 timing

Timing category 1More than 6 weeks since a positive COVID-19 test

Timing category 2Less than 6 weeks since a positive COVID-19 test

Testing considerationWhen less than 6 weeks have elapsed, no further testing is needed if TTE has been performed and symptoms have not worsened

Documentation Required

Document Hypertension or Pulmonary Hypertension

For suspected hypertensive heart disease or pulmonary hypertension, provide clear physician documentation supporting the suspicion and include the relevant diagnostic findings.

Hypertension: document suspected hypertensive heart disease, such as left ventricular hypertrophy on ECG
Pulmonary hypertension: document the physician's clear suspicion and relevant pulmonary hypertension findings
For primary pulmonary hypertension, describe when imaging is needed to guide therapy

Documentation Required

Include Aortic Disease Surveillance Details

For aortic root or thoracic aortic aneurysm surveillance, document the aneurysm size, interval change, and the conditions that affect surveillance frequency.

Initial six-month follow-up after thoracic aortic aneurysm diagnosis to measure the rate of change
If growth is greater than 0.5 cm per year, biannual imaging is allowed
Stable thoracic aortic aneurysm smaller than 4.5 cm: annual surveillance
Thoracic aortic aneurysm greater than 4.5 cm: biannual surveillance
Document known or suspected connective-tissue or genetic disease, including Marfan syndrome, Ehlers-Danlos syndrome, or Loeys-Dietz syndrome
For bicuspid aortic valve with thoracic aortic aneurysm and a first-degree family history of aortic dissection, biannual imaging is allowed

Documentation Required

Document the Post-COVID-19 Clinical History

For post-COVID-19 TTE requests, document the timing of the positive test, new symptoms, hospitalization details, troponin results, ventilation, and other findings that support targeted cardiac evaluation.

Positive COVID-19 test timing, including whether more than six weeks have elapsed
New-onset heart failure, unexplained arrhythmia, chest pain, shortness of breath, or ECG changes
Unusual fatigue that prevents the patient from performing prior activities of daily living
Prior hospitalization with positive troponins
Prior hospitalization requiring mechanical ventilation
Relevant medications, cardiac findings, and other clinical history when applicable

Denial Risk

Chest Pain With Concurrent Stress Testing

Do not submit a TTE to evaluate chest pain when an exercise treadmill test, myocardial perfusion imaging, or stress echocardiogram is being ordered concurrently to evaluate the same symptoms.

Concurrent exercise treadmill testing (ETT)
Concurrent myocardial perfusion imaging (MPI)
Concurrent stress echocardiography

Documentation Required

Palpitations Require Cardiac Findings

For palpitations, document signs or symptoms of cardiovascular disease or an ECG finding suggesting a cardiac etiology before requesting TTE.

Significant murmur
Ventricular arrhythmia on ECG
Atrial fibrillation on ECG
Other documented cardiovascular signs or symptoms

Denial Risk

Document the Type of Syncope

Do not request TTE for clearly documented vasovagal syncope or lightheadedness alone. Exercise-induced syncope is an approvable indication when documented.

Clearly documented vasovagal syncope or lightheadedness is not approvable
Document exercise-induced syncope when present

Documentation Required

Support a Pathologic Murmur

For a murmur, provide clear office-note documentation that its characteristics are pathologic or clinically significant and indicate reasonable suspicion of valvular or structural heart disease.

Diastolic murmur
Holosystolic murmur
Continuous murmur
Initial evaluation when valvular or structural heart disease is reasonably suspected

Denial Risk

Hypertension Must Include Cardiac Suspicion

For hypertension without suspected cardiac involvement, repeated TTE studies without new symptoms are not approvable. Document suspected hypertensive heart disease, such as left ventricular hypertrophy on ECG, when requesting the study.

Do not rely on hypertension alone
Repeated studies without new symptoms are not approvable
Provide evidence such as LVH on ECG when hypertensive heart disease is suspected

Denial Risk

Edema Requires Heart-Failure Findings

Edema alone does not support TTE. Document additional signs of congestive heart failure when present.

Shortness of breath
Rales on lung examination
S3 gallop
Other documented signs of congestive heart failure

Denial Risk

Routine Heart-Failure Surveillance

Yearly TTE for documented systolic or diastolic heart failure is not indicated without symptoms or a need to guide therapy. This restriction does not include the initial period when device management is being considered.

Document new or ongoing heart-failure symptoms
Explain how the study will guide therapy when applicable
Initial period of device-management consideration is an exception

Denial Risk

Mild Pulmonary Hypertension Without New Symptoms

Yearly TTE is not allowable for mild pulmonary hypertension when there are no new symptoms. Document new symptoms or the need to guide therapy, as applicable.

Mild pulmonary hypertension without new symptoms is not approvable for yearly surveillance
For primary pulmonary hypertension, request imaging as needed to guide therapy

Denial Risk

Avoid Low-Yield Isolated Findings

TTE is not approvable for isolated low-yield findings without qualifying symptoms, new findings, or another supported indication.

Sinus bradycardia alone
Atrial premature contractions (APCs) without atrial fibrillation or supraventricular tachycardia
Known coronary artery disease when prior MPI or left heart catheterization showed normal LVEF and there are no new symptoms
Trace valvular regurgitation without new symptoms

Denial Risk

Post-COVID-19 Testing Requires Qualifying Symptoms

When more than six weeks have elapsed since a positive COVID-19 test and there are no new symptoms, no further testing is needed. If TTE was performed less than six weeks after the positive test and symptoms have not worsened, additional testing is also unnecessary.

No new symptoms more than six weeks after a positive test: no further testing
Less than six weeks after a positive test with prior TTE and no worsening symptoms: no further testing
Qualifying new symptoms include chest pain, shortness of breath, or unusual fatigue preventing prior activities of daily living
Prior hospitalization with positive troponins or mechanical ventilation supports evaluation

Remote monitoring definition

More than 30 PVCs per hour

12-lead ECG definitionAt least 1 PVC

Post-COVID-19 targeted cardiac evaluation

PopulationSelected patients after COVID-19 infection

Qualifying findingsNew-onset heart failure, unexplained cardiac arrhythmias, chest pain, shortness of breath, or ECG changes

PurposeCardiac testing is considered when it is likely to change management or guide prognosis