CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Myocardial Strain Imaging

Clinical review criteria governing coverage of myocardial strain imaging (MSI) using speckle-tracking echocardiography for Kaiser Foundation Health Plan of Washington members; specifies medical necessity for non-Medicare members related to oncology medication exposure and designates other indications as experimental/investigational.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Myocardial Strain Imaging

Policy CodePolicy N/A

Change TypeRevised (adopted criteria; MPC approvals)

Effective DateJul 1, 2022

Next Review DateApr 1, 2025

Key ActionWhen requesting MSI, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

POLICY UPDATE CHANGES

MPC approved to adopt criteria for Myocardial Strain Imaging with 60-day notice, effective date 07/01/2022.

1Covered indication (oncology-related cardiotoxicity monitoring)

All othersConsidered experimental/investigational

LowEvidence quality

Coverage Summary

This policy defines clinical review criteria for Myocardial Strain Imaging (MSI) using speckle-tracking echocardiography for Kaiser Foundation Health Plan of Washington members, specifying medical necessity primarily for oncology medication–related cardiotoxicity monitoring and designating other uses as experimental or unproven. MSI analyzes echocardiographic images by tracking stable ‘‘speckles’’ in the myocardium with software to assess myocardial deformation, mechanics, and function. The evidence base is overall low quality with limited, inconsistent diagnostic and prognostic data and a lack of studies demonstrating clinical utility. Effective date: 2022-07-01; Last review: 2024-04-02; Next review: 2025-04-01.

Medical Necessity Criteria

Non-Medicare Members - Medically Necessary Indication

Myocardial strain imaging is considered medically necessary when ANY of the following apply:

ANY of the following

Prior to exposure to oncology medications that could result in cardiotoxicity
During exposure to oncology medications that could result in cardiotoxicity
Following exposure to oncology medications that could result in cardiotoxicity

Examples of oncology medications included

doxorubicin (Adriamycin)
trastuzumab (Herceptin, Kanjinti)
pertuzumab (Perjeta)
ado-trastuzumab emtansine (Kadcyla)
fam-trastuzumab deruxtecan (Enhertu)
mitoxantrone (Novantrone)
liposomal doxorubicin (Doxil)

Documentation Required to Support Medical Necessity

Provide last 6 months of clinical notes from requesting provider and/or specialist

Medicare Members

Kaiser policy statement when no CMS/NCD/LCD guidance exists

No applicable CMS Coverage Manuals, National Coverage Determinations (NCD), Local Coverage Determinations (LCD), or Local Coverage Articles (LCA) identified

Refer to Non-Medicare criteria for medical necessity determinations

Not Medically Necessary / Experimental

Not Medically Necessary / Experimental, Investigational, or Unproven

MSI is considered experimental, investigational or unproven for:

All indications other than the specified oncology-medication related uses (prior to, during, or following exposure to cardiotoxic oncology medications)

Myocardial strain imaging is considered medically necessary for monitoring cardiotoxicity in relation to oncology medication exposure (prior to, during, or following exposure) and is considered experimental/investigational for all other indications. The policy statistics reflect this stance: there is 1 covered indication category (oncology-related cardiotoxicity monitoring) and All others are labeled as experimental.

Provider Actions

Documentation Required

Clinical notes submission

When requesting MSI, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Last 6 months of clinical notes

Prior Authorization

Verify authorization requirements

Verify authorization requirements for the specific CPT code and plan type using the Pre-authorization Code Check tool before service.

93356

Denial Risk

Not covered for non-oncology indications

Claims for MSI (CPT 93356) for indications other than prior to, during, or following exposure to cardiotoxic oncology medications are considered experimental/investigational and may be denied.

93356
May be denied if non-oncology indication

Background, Evidence & Definitions

Myocardial strain imaging (MSI) uses speckle-tracking echocardiography: image-processing software follows stable bright/dark ‘‘speckles’’ produced by ultrasound reflections to track myocardial wall segments and assess damage or dysfunction. Although MSI requires less complex equipment than cardiac MRI, it may be less accurate; only one study directly compared MSI with MRI. The overall evidence quality is low, with inconsistent results across studies and a lack of clinical utility data demonstrating that MSI-guided care improves outcomes.

Source	Summary
Hayes assessment	Hayes Health Technology Assessment: Myocardial Strain Imaging by Speckle-Tracking Echocardiography 2022
Quality of evidence	Overall low quality; limited and inconsistent diagnostic/prognostic data; lack of clinical utility studies

Definitions

Myocardial Strain Imaging (MSI)Analysis of echocardiographic images using speckle-tracking software to assess myocardial deformation, mechanics, and function.

Revision History

01/18/2022MPC approval

MPC Medical Policy Committee reviewed myocardial strain imaging criteria (Date Reviewed: 01/18/2022).

02/01/2022MPC approval

MPC approved adoption of criteria for Myocardial Strain Imaging with 60-day notice; effective date 07/01/2022.

02/07/2023MPC approval

MPC Medical Policy Committee review of myocardial strain imaging criteria (02/07/2023).

04/02/2024MPC approval

MPC Medical Policy Committee review of myocardial strain imaging criteria (04/02/2024).

04/01/2025MPC approvalLatest

MPC Medical Policy Committee review of myocardial strain imaging criteria (04/01/2025).

07/01/2022Adoption effective date

MPC approved adoption of criteria for Myocardial Strain Imaging with 60-day notice; criteria effective 07/01/2022.