L29227 MICROVOLT T-WAVE ALTERNANS

 

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Medicare will consider microvolt TWA medically reasonable and necessary when:

o performed for a clinical condition associated with a high risk of ventricular tachyarrhythmias

 Ischemic cardiomyopathy.

 Unexplained syncope with suspected.

 Known heart disease, etc.

 Only when the results of the test will be used in the management of the patient.

• For example, the results of the microvolt TWA will determine whether a patient will undergo an invasive electrophysiological study or treatment with antiarrhythmics when the results are positive.

• Microvolt TWA is NOT covered for

o The general assessment of a patient with atherosclerotic heart disease.

o Pre-surgical evaluation or other circumstances where the index of suspicion of ventricular tachycardia/fibrillation is low.

o The knowledge of possible ventricular tachycardia/fibrillation will not alter the management of the patient.

 Also, the routine use of microvolt TWA as an add-on service to other cardiac evaluation tests such as electrocardiograms, stress testing, and electrophysiologic studies is not covered.

• Effective for dates of service on or after March 21, 2006, Microvolt T-wave Alternans (MTWA) diagnostic testing is covered for the evaluation of patients at risk of sudden cardiac death (SCD), only when the spectral analysis method is used.

o Within patient groups that may be considered candidates for implantable cardioverter defibrillator (ICD) therapy, a negative MTWA test may be useful in identifying low-risk patients who are unlikely to benefit from, and who may experience worse outcomes from ICD placement.

• The test is performed by placing highly sensitive electrodes on a patient’s chest prior to a period of controlled exercise.

o These electrodes detect tiny beat-to-beat changes, on the order of one-millionth of volt, in the EKG T-wave.

o Spectral analysis is used to calculate these minute voltage changes.

o Spectral analysis is a sensitive mathematical method of measuring and comparing time and the EKG signals.

o Software then analyzes these microvolt changes and produces a report to be interpreted by a physician.

Limitations:

• Microvolt T-wave Alternans diagnostic testing in non-covered for the evaluation of patients at risk for SCD if measurement is not performed employing the spectral analysis method for services performed on or after March 21, 2006.

 

 

CPT/HCPCS Codes

 

93025 MICROVOLT T-WAVE ALTERNANS FOR ASSESSMENT OF VENTRICULAR ARRHYTHMIAS

 

 

ICD-9 Codes that Support Medical Necessity

 

402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

404.00 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.02 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.10 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.12 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.90 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.92 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

410.00 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED

410.01 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE

410.02 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

410.10 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED

410.11 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL INITIAL EPISODE OF CARE

410.12 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE

410.20 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED

410.21 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL INITIAL EPISODE OF CARE

410.22 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

410.30 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED

410.31 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL INITIAL EPISODE OF CARE

410.32 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE

410.40 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED

410.41 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL INITIAL EPISODE OF CARE

410.42 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE

410.50 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED

410.51 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL INITIAL EPISODE OF CARE

410.52 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE

410.60 TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED

410.61 TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE

410.62 TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE

410.70 SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED

410.71 SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE

410.72 SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE

410.80 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED

410.81 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES INITIAL EPISODE OF CARE

410.82 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE

410.90 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED

410.91 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE INITIAL EPISODE OF CARE

410.92 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.1 INTERMEDIATE CORONARY SYNDROME

411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION

411.89 OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

412 OLD MYOCARDIAL INFARCTION

414.10 ANEURYSM OF HEART (WALL)

414.19 OTHER ANEURYSM OF HEART

414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE

425.0 ENDOMYOCARDIAL FIBROSIS

425.1 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

425.2 OBSCURE CARDIOMYOPATHY OF AFRICA

425.3 ENDOCARDIAL FIBROELASTOSIS

425.4 OTHER PRIMARY CARDIOMYOPATHIES

425.5 ALCOHOLIC CARDIOMYOPATHY

425.7 NUTRITIONAL AND METABOLIC CARDIOMYOPATHY

425.8 CARDIOMYOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

425.9 SECONDARY CARDIOMYOPATHY UNSPECIFIED

426.82 LONG QT SYNDROME

427.1 PAROXYSMAL VENTRICULAR TACHYCARDIA

427.41 VENTRICULAR FIBRILLATION

427.42 VENTRICULAR FLUTTER

427.5 CARDIAC ARREST

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.1 LEFT HEART FAILURE

428.20 UNSPECIFIED SYSTOLIC HEART FAILURE

428.21 ACUTE SYSTOLIC HEART FAILURE

428.22 CHRONIC SYSTOLIC HEART FAILURE

428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 UNSPECIFIED DIASTOLIC HEART FAILURE

428.31 ACUTE DIASTOLIC HEART FAILURE

428.32 CHRONIC DIASTOLIC HEART FAILURE

428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

746.89 OTHER SPECIFIED CONGENITAL ANOMALIES OF HEART

780.2 SYNCOPE AND COLLAPSE

 

 

Documentation Requirements

 

• Medical record documentation must clearly indicate the medical necessity of the service(s) being billed and that the results of the test are being used in the management of the patient.

• In addition, the documentation must support that the procedure was performed.

• The procedure report should include documentation and interpretation of spectral analysis for services performed on or after March 21, 2006.

• This information is normally found in the office/progress notes, hospital records, and test results.

 

 

Treatment Logic

 

• Microvolt T-wave alternans (TWA) is an every other beat variation in the T-wave that is predictive of ventricular tachyarrhythmias associated with sudden cardiac death.

• Microvolt TWA is measured through sensors and electrodes placed in the standard 12-lead configuration as well as additional vector positions during a routine exercise stress test, pharmacologic stress test or cardiac pacing.

• Sustained alternans with an onset of the heart rate less than 110 bpm for a minimum of 2.5 minutes with alternans voltage measured at > 1.9 microvolts and alternans ratio of >3 is considered a positive t-wave alternans.

 

 

Sources of Information and Basis for Decision

 

Barron, H. (2000). Editorial Comment: T-wave alternans and serious ventricular arrhythmias: a tale of two t-waves. Journal of the American College of Cardiology, 36(7), 2254-2256. Supported validity of test for coverage.

 

Bloomfield, D.M. (2006). Microvolt T-wave alternans and the risk of death or sustained ventricular arrhythmias in patients with left ventricular dysfunction. Journal of the American College of Cardiology. 47(2): 456-63.

 

Cambridge Heart Inc. (2001). Microvolt T-wave alternans: A tool for predicting arrhythmia and sudden cardiac arrest. Retrieved October 10, 2001, from Cambridge Heart database on the World Wide Web: http//www.cambridgeheart.com/camh/professional/newtool.html. Used in the description of the service.

 

Cohen, R. (2001). Use of microvolt t-wave alternans testing in clinical practice to reduce cardiac arrest and sudden cardiac death. Scheduled for publication in EP Lab Digest, September, 2001. Used in description of the service and supports the clinical conditions for coverage.

 

Gold, M., Bloomfield, D., Anderson, K., El-Sherif, N., Wilber, D., Groh, W., Estes, M., Kaufman, E., Greenberg, M., & Rosenbaum, D. (2000). A comparison of t-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification. Journal of the American College of Cardiology, 36(7), 2247-2253. Provided information regarding a positive test used in the description.

 

Hennersdorf, M., Perings, C., Niebch, V., Vester, E., & Strauer, B. (2000). T wave alternans as a risk predictor in patients with cardiomyopathy and mild-to-moderate heart failure. PACE, 23, 1386-1391. Supports potential indication for coverage.

 

Ikeda, T., Sakata, R., Takami, M., Kondo, N., Tezuka, N., Nakae, T., Noro, M., Enjoji, Y., Abe, R., Sugi, K., & Yamaguchi, T. (2000). Combined assessment of t-wave alternans and late potentials used to predict arrhythmic events after myocardial infarction. Journal of the American College of Cardiology, 35(3), 722-730. Supports potential indication for coverage.

 

Ikeda, T., Saito, H., Tanno, K., Shimizu, H., Watanobe, J., Ohnishi, Y., Kasamaki, Y., & Ozawa, Y. (2002). T-wave alternans as a predictor for sudden cardiac death after myocardial infarction. The American Journal of Cardiology, 89, 79-82. Indicates TWA could be used in the primary screening of patients for sudden cardiac death after MI.

 

Izzo, J.L. (2004). Mechanisms and management of hypertensive heart disease: from left ventricular hypertrophy to heart failure. Med Clinics North Am 88(5):1257-71.

 

Kitamura, H., Ohnishi, Y., Okajima, K., Ishida, A., Galeano, E., Adachi, K., & Yokoyama, M. (2002). Onset heart rate of microvolt-level t-wave alternans provides clinical and prognostic value in nonischemic dilated cardiomyopathy. Journal of the American College of Cardiology, 39(2), 295-300. Supports TWA as a risk stratifier for patients with DCM at risk for sudden cardiac death.

 

Klingenheben, T., Zabel, M., D’Agostino, R., Cohen, R., & Hohnloser, S. (2000). Predictive value of t-wave alternans for arrhythmic events in patients with congestive heart failure. The Lancet, 356, 651-652. Supports potential indication for coverage.

 

Tapanainen, J., Still, A., Airaksinen, K., & Huikuri, H. (2001). Prognostic significance of risk stratifier of mortality, including t wave alternans, after acute myocardial infarction: Results of a prospective follow-up study. Journal of Cardiovascular Electrophysiology, 12(6), 645-652. Indicates that additional studies are needed to assess the prognostic power of TWA in post AMI populations.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

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Local Coverage Determination (LCD) Microvolt T-wave Alternans (L29227)