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TRANSTHORACIC ECHOCARDIOGRAPHY

Protocol: CAR033 Effective Date: July 2, 2010 Table of Contents Page

COMMERCIAL COVERAGE RATIONALE......................................................................................... 1 MEDICARE & MEDICAID COVERAGE RATIONALE...................................................................... 2 BACKGROUND .................................................................................................................................... 11 CLINICAL EVIDENCE......................................................................................................................... 11 U.S. FOOD AND DRUG ADMINISTRATION (FDA) ........................................................................ 13 APPLICABLE CODES .......................................................................................................................... 14 REFERENCES ....................................................................................................................................... 23 PROTOCOL HISTORY/REVISION INFORMATION ........................................................................ 25 INSTRUCTIONS FOR USE This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Certificate of Coverage (COC) or Summary Plan Description (SPD)) may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this Medical Policy. Other Protocols, Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute medical advice.

COMMERCIAL COVERAGE RATIONALE Transthoracic echocardiography is medically necessary for diagnosing and monitoring heart disease in children and adolescents 17 years of age or younger. Transthoracic echocardiography is medically necessary for evaluating cardiac structure and function in persons over 17 years of age for the following indications: 1. Symptoms due to suspected cardiac etiology; including, but not limited to, shortness of breath, lightheadedness, syncope, transient ischemic attack (TIA) or cerebrovascular events, or 2. Known or suspected adult congenital heart disease, pulmonary hypertension, heart failure, Marfan syndrome or cardiomyopathy, or 3. Arrhythmias, or 4. Left ventricular function following myocardial infarction, or 5. Hypotension or hemodynamic instability, or

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6. Acute chest pain or ischemic heart disease, or 7. Respiratory failure, or 8. Known or suspected acute pulmonary embolism to guide therapy (i.e., thrombectomy and thrombolytics), or 9. Heart murmurs and valvular dysfunction (native or prosthetic valves), or 10. Thoracic or thoracoabdominal aortic aneurysm or dissection, or 11. Infective endocarditis (native or prosthetic valves), or 12. Suspected cardiac tumor, thrombus or embolic event, or 13. Pericardial disease (including, but not limited to, pericardial effusion or pericarditis), or 14. Suspected hypertensive heart disease, or 15. Pacing device dysfunction, or 16. Patients undergoing therapy with cardiotoxic agents (baseline and re-evaluation), or 17. Patients with a family history of genetically transmitted cardiovascular disease, or 18. Potential donors for cardiac transplantation, or 19. First-degree relatives (parents, siblings, children) of patients with unexplained dilated cardiomyopathy in whom no etiology has been identified. Transthoracic echocardiography is not medically necessary for screening in the general population, including asymptomatic athletes. Although noninvasive testing can enhance the diagnostic power of the standard history and physical examination, the American Heart Association does not recommend the routine use of echocardiography in the context of mass, universal screening. Transthoracic echocardiography is not medically necessary for the initial evaluation of suspected pulmonary embolism in order to establish a diagnosis. Large differences exist in the accuracy of diagnostic tests used to confirm or rule out pulmonary embolism. Patients with a negative echocardiography result and a normal venous ultrasonography result require additional testing to rule out pulmonary embolism, even when the clinical probability is low.

MEDICARE & MEDICAID COVERAGE RATIONALE Medicare does not have a National Coverage Determination for Transthoracic Echocardiography. There is a Local Coverage Determination for Nevada for Echocardiography, Transthoracic and Transesophageal. The Local Coverage Determination is as follows: Echocardiography is indicated in the evaluation of derangements of valvular, myocardial, pericardial and thoracic aortic anatomy and function. Major applications for coverage fall into the following clinical settings. The following clinical conditions are covered for transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) when TTE or TEE diagnostic testing directly contributes to the management or diagnosis of disease.

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1. Disease of Native Cardiac Valves Detection of mitral stenosis was among the first practical clinical applications of TTE. TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of valvular pathologies can be quantified. Visualization of the valve and valvular apparatus provides information to facilitate therapeutic decision making when competing therapeutic options exist and TTE is likely to resolve these alternatives. Serial evaluations may be clinically appropriate, for example, in the monitoring of chronic aortic pathology when images suitable for serial quantitation are required for care management decisions. 2. Prosthetic Heart Valves TTE assessment soon after prosthetic valve surgery is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Features evaluated include valvular position and function, underlying ventricular function and concomitant valvular pathologies, if any. TEE is indicated when prosthetic dysfunction is suspected or therapeutic decisions are pivotal and data is inconclusive. However, TEE is not routinely indicated in all patients with prosthetic valves. 3. Acute Endocarditis Echocardiography provides diagnostic information pertaining to valvular pathology, vegetative masses and ventricular function. Larger vegetations may be visualized with TTE, and TTE is generally better able to define the consequences of the infective valvular process on ventricular function. TEE on the other hand, may better define smaller vegetative masses and more completely delineate local complications such as ring abscesses, aneurysms, or fistulae. In most cases TEE is not indicated as the initial evaluation in the diagnosis of native valvular endocarditis. If TTE visualization is insufficient due to body habitus (obesity, increased thoracic diameter due to chronic obstructive pulmonary disease, other anatomical characteristics) then TEE would be indicated to provide a clear initial diagnostic test for acute endocarditis. Examination frequency in the acute phase of illness is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE (or TEE) evaluation will be determined by the residual pathophysiology and discrete clinical events. 4. Ventricular Function and Cardiomyopathies Changes in myocardial thickness (hypertrophy and thinning), chamber volume, size and morphology as well as derived parameters of contractility can be quantified and charted over time by TTE. Therapeutic interventions can be assessed by repeat evaluation. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. There is increasing data to support the prognostic value of diastolic function parameters in patients with systolic dysfunction.

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TTE is only one method for evaluating ventricular function. Alternative methods include left ventricular angiography, gated blood pool scans and certain CT and MRI procedures. TTE and gated blood pool scans are the least costly methods of obtaining this information. Gated blood pool scans are more quantitative while TTE yields better information about wall thickness and valve function. In most cases, only one method of assessment is needed and this should be the most cost-effective method to answer the clinical question. Care should meet, but not exceed, the patient's need. In general, TTE provides accurate and serial non-invasive assessment of global and regional left ventricular function. TTE assessment of left ventricular function is considered preferable to TEE. For stable patients absent documented deterioration, repeated examinations more frequently than annually are not medically necessary. 5. Acute Myocardial Infarction and Coronary Insufficiency Echocardiography is covered for the evaluation of patients with symptoms of acute myocardial infarction when the standard battery of tests is inconclusive or when clinical decision making would be significantly affected by immediate assessment of myocardial and/or valvular function. TTE may detect depressed myocardial contractility or complications of acute myocardial infarction such as mural thrombi, papillary muscle dysfunction and/or rupture, septal defects, true or false aneurysms, and myocardial rupture. Repeat echocardiography assessment may be repeated as early as six weeks following myocardial infarction. Thereafter, repeat echocardiography, in the absence of clinical changes, requires additional justification. TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. The role for TTE in the emergency room assessment of individuals who present with chest pain is in evolution. This application may be used as part of a thoughtful clinical evaluation, and in making a triage decision on a patient with chest pain syndrome. 6. Hypertensive Cardiovascular Disease TEE may be indicated in individuals with hypertension who have clinical evidence of heart disease. Left ventricular hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. TTE can be used to monitor changes in the left ventricle that might indicate the need for or beneficial results of long-term antihypertensive therapy.

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In young individuals and in individuals with borderline hypertension, the decision to commit to longterm antihypertensive therapy may be determined in part by the presence of left ventricular hypertrophy and /or left ventricular mass calculation. 7. Cardiac Transplant and Rejection Monitoring TTE is an integral part of the cardiac donor selection and recipient matching process. Evaluations focus on analysis of ventricular function and the integrity of cardiac valves. Intraoperative TEE is appropriate in heart-lung transplants where the integrity and morphology of the pulmonary vascular anastomoses are critical. TTE is also used in the management of allograft recipients. TTE will determine myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid which may be signs of a rejection episode. TTE may be required weekly for the first four to eight weeks following transplant with decreasing frequency thereafter. Three TTE examinations are typically performed yearly in chronic transplant recipients in the absence of clinical deterioration or evidence of rejection. 8. Exposure to Cardiotoxic Agents (Chemotherapeutic and External) Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. When echocardiography is used to monitor cardiac toxicity of chemotherapeutic agents, an initial complete TTE may be performed prior to the first administration of the agent with the frequency of repeat studies determined by the patient's clinical course and the toxicity profile of the agent being administered. 9. Pericardial Disease Detection and quantification of pericardial effusion is an important application of TTE. Small pericardial fluid accumulations (20 ml) have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. Certain TTE findings have been found to be reliable indices of cardiac tamponade. TTE facilitates removal of pericardial fluid and the creation of pericardial windows. The acute clinical status will dictate examination frequency. TTE and doppler techniques are quite helpful in identifying pericardial constriction and differentiating it from restrictive myocardial disease. 10. Congenital Heart Disease In children and young adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with doppler hemodynamic measurements, TTE usually provides accurate diagnosis and noninvasive serial assessment. 11. Cardiac Tumors and Masses TTE may assess infiltrative and ventricular tumors and masses, right atrial masses, and their hemodynamic consequences. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, attachments, etc.). These pathologies are not typically followed serially.

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12. Critically Ill and Trauma Patients There is a role for echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspected aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the patient's clinical status and decision-making requirements. 13. Suspected Cardiac Thrombi and Embolic Sources TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial appendages and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias such as atrial fibrillation, cardiomyopathies and ventricular dysfunction) TTE usually provides adequate supplemental therapeutic decisional data. In those instances where the precise diagnosis and localization of potentially embolic material is of paramount therapeutic importance and the information so obtained will potentially and substantively alter therapy, or the risk of anticoagulants is inordinately high, consideration should be given to TEE if TTE provides inadequate information for clinical decisions. 14. Contrast Echocardiography Contrast TTE is indicated when a conventional study has failed to provide adequate and critically needed information on left ventricular function. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient. 15. Chronic Ischemic Heart Disease TTE may be used at rest (and with exercise) in persons with chronic ischemic heart disease for diagnosis, risk stratification, and medical management decision making. At rest, TTE is useful in demonstrating left ventricular function and wall motion as well as valvular and papillary muscle function that are often abnormal in ischemic states. 16. Aortic Pathology TTE can provide valuable information when acute or chronic aortic pathology is present. TTE is indicated for the investigation of aortic ulceration, atherosclerotic plaque and mural thrombotic material. TEE may be appropriate for documenting aortic lesions if embolic episodes are repetitive and surgical intervention is contemplated. Because of the posterior position of the thoracic aorta and the image span of the TEE window, TEE is a more definitive study of aortic dissection and aneurysm than TTE. In suspected aortic dissection and aortic trauma, TEE is frequently considered the diagnostic study of choice.

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17. Interventional and Surgical TEE TEE can be of use during percutaneous and surgical cardiac interventions. In selected instances, TEE can provide guidance during the creation of shunts, placement of septation devices, performance of valvular plastic procedures and replacement, when the surgical result cannot be adequately assessed by other means. Prior to elective percutaneous mitral valvuloplasty, TEE is used to assess left atrial thrombi. TEE may be used to assess cardiac organ donors before harvesting decisions are made. In lung or heart-lung transplant, the integrity and morphology of pulmonary vascular anastomoses is critical. Intraoperative TEE can assist in surgical management decisions. In select high-risk patients, intraoperative TEE may monitor ventricular function, complementing hemodynamic monitoring data. Assessment for volume status and global and regional myocardial contractility can be therapeutically useful. However, routine use of TEE in non-high risk valvular surgeries or bypass surgeries such as CABG is not supported. 18. Arrhythmias Echocardiography is covered for assessment of patients with certain cardiac arrhythmias (atrial fibrillation, atrial flutter, ventricular tachycardia and ventricular fibrillation) to identify underlying structural or functional cardiac abnormalities identifiable by echocardiography and for which test results will influence treatment decisions. 19. Cardioversion When cardioversion is required to treat atrial fibrillation or flutter, an echocardiogram prior to the procedure may be reasonable and necessary when the patient is at high risk for embolization, such as those who:

· · · · ·

Have had an embolic event from atrial fibrillation in the past, Have had an adverse event following a previous attempt at cardioversion, Are not on anticoagulation therapy, Have been on inadequate anticoagulation therapy, or Have had previously demonstrated left atrial thrombus.

TEE may be of use in those patients for whom anticoagulation is contraindicated and therefore they are not anti-coagulated. When the patient is anti-coagulated adequately, TTE will usually suffice as a pretreatment assessment for thrombi. 20. Palpitations and Syncope Echocardiography may be used to evaluate palpitations or syncope only when there is clinical suspicion of heart disease and when standard electrocardiography testing (resting ECG, 24 Hour Holter Monitoring, stress testing) have been negative or equivocal.

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21. Difficult to Control Hypertension Echocardiography may be used to assess diastolic function in patients with difficult to control hypertension, for the guidance of treatment decisions. Echocardiography is not indicated for patients with controlled hypertension. 22. Pulmonary Heart Disease Echocardiography is useful in the evaluation and monitoring of right sided heart failure due to pulmonary hypertension or other types of pulmonary disease in which the right ventricle must pump against high pressures in the lungs. Frequency of periodic reassessment will be dictated by clinical status and interventions. 23. Transesophageal Cardiac Output Monitoring ­ Effective 5/17/2007, this service can be covered, when medically required, for ventilated ICU patients and inpatient/outpatient surgical patients. Change Request 5608 instructs providers to use unlisted CPT code 76999-26 for this service. Limitations Echocardiographic studies are not payable by Medicare when they are not reasonable and necessary to obtain clinically significant diagnostic or monitoring information. The contractor will utilize recognized resources such as the American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines in such determinations. 2. The utilization of contrast should not be routine protocol in the laboratory/office setting. Patients requiring contrast should be carefully selected and the decision to use contrast should be made following a pre-contrast study and an assessment of echocardiographic data. 3. Studies without, and then with, contrast will be considered a single study, whether performed on the same or sequential days. 4. Contrast echocardiography is not covered when used to evaluate perfusion. Training Requirements The following training requirements do not apply to hospital in-patient or out-patient echocardiography services. The contractor itself does not credential providers. Medicare does expect a satisfactory level of competence from providers who submit claims for services rendered. Medicare services are only payable when performed by appropriate staff in an appropriate setting (explicitly stated in the Medicare Program Integrity Manual, Pub. 100-08, Chapter 13). Substandard studies are associated with unnecessary repetition of studies and overutilization of services. Substandard studies can directly endanger the patient if medical conditions are not able to be diagnosed because of a poorly or

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improperly conducted study, or, medical conditions are not recognized because the level of expertise of the interpreter does not meet accepted professional standards. The most commonly cited professional standard is that of the ACC/AHA (American College of Cardiology, American Hospital Association; For transthoracic echo, Level 1 experience is defined as "not sufficient to perform or interpret echocardiograms independently," Level 2 experience is a level appropriate for independent practice of echocardiograms, and Level 3 experience is appropriate for a center director. The acceptable levels of competence are: For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions: 1. The service is performed personally by a physician with full training in cardiac structure and function, the acquisition of echocardiography images, echocardiographic equipment functions, and trouble shooting, e.g. similar to Level 2 experience of the ACC/AHA; or 2. The service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or 3. The service is performed at a laboratory (e.g. office, IDTF), credentialed by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). Note that the national supervision level is 1 (general supervision) for TTE and 3 (personal supervision) for the technical component of TEE. You may find the current year CMS RVU/fee schedule database (e.g. PPRRVU06.xls, column Z) at www.cms.hhs.gov. For the professional portion (interpretation), an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting one of the following requirements: For Transthoraic Echocardiography (TTE) and/or Transesophageal Echocardiography (TEE): 1. The physician is ABIM board certified or board eligible in Cardiovascular Diseases; OR 2. The physician provides the interpretation in conjunction with a study that was performed at a laboratory that is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and that is subject to such laboratory's quality assurance policies and procedures (the ICAEL website is www.intersocietal.org/icael/apply/standards.htm). For Transthoracic Echocardiography (TTE): 1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography. Level II training is the basic level for independent practice. OR

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2. The equivalent of Level II training of the ACC/AHA. This A/B MAC requires that this training must be obtained by working under a mentor who is fully qualified to teach and supervise, e.g. Level III training of the ACC/AHA. ("Training and competence" are not demonstrated by prior reimbursement for multiple procedures by Medicare prior to the implementation of this LCD). OR 3. The physician has staff privileges to interpret hospital transthoracic echocardiograms at a hospital that participates in the Medicare program. This A/B MAC further requires that the physician must be authorized by the hospital to interpret any and all TTE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL. For Transesophageal Echocardiography (TEE), professional competence is fulfilled when: 1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, OR 2. NBE (National Board of Echocardiography) certification in TEE, OR 3. The equivalent of Level II training in TTE, AND additional training specific to TEE which should include: 1) A letter or certificate from the training supervisor (training program director, echocardiography laboratory director, or equivalent) documenting performance and interpretation of 50 supervised TEE cases, OR 4. The physician has staff privileges to interpret hospital TEE at a hospital that participates in the Medicare program. This A/B MAC further requires that the physician must be authorized by the hospital to interpret any and all TEE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL. OR 5. The provider performs cardiovascular anesthesiology with experience in TEE. For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. http://www.cms.hhs.gov/mcd/search Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services' Website.

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BACKGROUND Echocardiography uses high-frequency sound waves to create moving images of the heart for the diagnosis and management of cardiovascular disease. The procedure can be used to diagnose cardiovascular problems, guide treatment decisions, monitor changes and determine the need for additional tests. An echocardiogram shows the size, structure and movement of different parts of the heart, including the valves, septum and heart chambers. Doppler ultrasound techniques may also be used to record blood flow within the heart. Because echocardiography is a form of ultrasound, it does not involve the use of radiation. Transthoracic echocardiography (TTE) is a noninvasive test that uses a wand-like device, called a transducer, to send sound waves through the chest wall. As the sound waves bounce off the structures of the heart, a computer converts them into pictures (NHLBI website).

CLINICAL EVIDENCE Valvular insufficiency Echocardiography with Doppler has recently emerged as the method of choice for the non-invasive detection and evaluation of the severity and etiology of valvular regurgitation. Characterization of the severity of regurgitant lesions is among the most difficult problems in valvular heart disease. Such a determination is important since mild regurgitation does not lead to remodeling of cardiac chambers and has a benign clinical course, whereas severe regurgitation is associated with significant remodeling, morbidity and mortality (Zoghbi 2003). Routine screening The American Heart Association (AHA) continues to support preparticipation cardiovascular screening for student-athletes and other participants in organized competitive sports as justifiable, necessary, and compelling on the basis of ethical, legal, and medical grounds. Noninvasive testing can enhance the diagnostic power of the standard history and physical examination. However, the AHA panel does not believe it to be either prudent or practical to recommend the routine use of tests such as 12-lead ECG or echocardiography in the context of mass, universal screening (Maron 2007). In a 2003 joint statement, the American College of Cardiology (ACC) and the American Heart Association (AHA) made the following recommendations regarding screening in the absence of symptoms: (Cheitlin 2003) Recommendations for Echocardiography to Screen for the Presence of Cardiovascular Disease Class I (conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective) 1. Patients with a family history of genetically transmitted cardiovascular disease. 2. Potential donors for cardiac transplantation. 3. Patients with phenotypic features of Marfan syndrome or related connective tissue diseases. 4. Baseline and re-evaluations of patients undergoing chemotherapy with cardiotoxic agents. 5. First-degree relatives (parents, siblings, children) of patients with unexplained dilated

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cardiomyopathy in whom no etiology has been identified. Class IIa (conditions for which the weight of evidence/opinion is in favor of usefulness/efficacy) There are no screening recommendations in this category. Class IIb (conditions for which usefulness/efficacy is less well established by evidence/opinion) Patients with systemic disease that may affect the heart. Class III (conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful) 1. The general population. 2. Routine screening echocardiogram for participation in competitive sports in patients with normal cardiovascular history, ECG, and examination. Pulmonary embolism In a systematic review and meta-analysis, Roy et al. (2005) stated that large differences exist in the accuracy of diagnostic tests used to confirm or rule out pulmonary embolism. Patients with a negative echocardiography result and a normal venous ultrasonography result would require additional testing to rule out pulmonary embolism, even when the clinical probability was low. Therefore, echocardiography and ultrasonography appear to be unable to exclude pulmonary embolism. Professional Societies American College of Cardiology (ACC) The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) in partnership with the American College of Emergency Physicians (ACEP), American Society of Nuclear Cardiology (ASNC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT) and the Society for Cardiovascular Magnetic Resonance (SCMR) developed appropriateness criteria that assess the risks and benefits of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) for several indications or clinical scenarios. In general, the use of TTE/TEE for the initial evaluation of structure and function was viewed favorably, while routine repeat testing and general screening used in certain clinical scenarios were viewed less favorably. These criteria have also been endorsed by the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) (Douglas 2007). American College of Radiology (ACR) Acute chest pain TTE and TEE with or without pharmacologic stress are frequently used to define abnormalities of ventricular wall motion as an indicator of cardiac disease. In addition, echocardiography can readily demonstrate pericardial effusion, valve dysfunction and cardiac thrombus. Aortic pathology can be identified, but the findings of intramural hematoma, dissection, pulmonary embolus and aneurysm are better seen with multidetector computed tomography MDCT or magnetic resonance imaging (MRI ) (ACR 2008a). TTE is useful in the diagnosis of dissection involving the ascending aorta, but is of limited value in diagnosing distal dissections (ACR 2008b). TTE is generally not indicated in the workup of acute chest pain in suspected acute pulmonary embolism (PE). However, it may be helpful in evaluating right ventricular function in suspected chronic, major-vessel thromboembolic pulmonary

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hypertension or in evaluating risk of right heart failure in patients with massive or submassive acute PE. Sonography may be a useful adjunct, but it cannot exclude PE. (ACR 2006a) Chronic chest pain TTE can be used to demonstrate left ventricular regional dysfunction due to ischemia, regional wall motion abnormalities and structural heart disease (ACR 2008c). It can also be used to exclude ischemic cardiac disease and assess for valvular or pericardial disease as a cause for chronic chest pain in patients with a low to intermediate probability of coronary disease (ACR 2008d). Shortness of breath TTE plays an important role in evaluating patients with dyspnea of suspected cardiac origin. (ACR 2006b) Suspected bacterial endocarditis TTE can demonstrate vegetations on cardiac valves, valvular regurgitation and perivalvular abscess and is the most frequently used imaging study for confirming the diagnosis of infective endocarditis. TTE is the procedure of choice for patients with intermediate or high probability of endocarditis. (ACR 2006c) Suspected congenital heart disease Despite some limitations, TTE remains a firstline imaging examination in adults with suspected congenital heart disease (CHD) and has long been established as a clinically useful diagnostic modality for CHD in children. (ACR 2007) American Academy of Pediatrics (AAP) For pediatric echocardiography laboratory standards, the AAP endorses accreditation by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and adherence to ACC/AHA guidelines. For ICAEL accreditation of pediatric transthoracic, transesophageal or fetal echocardiography, a laboratory must show that it has state-of-the-art equipment and facilities suitable for children, follows good technique in recording and reporting examinations and is staffed by physicians and technicians trained in pediatric echocardiography. (AAP 2002) Additional search terms echo, surface echo, heart ultrasound, sonogram, cardiac ultrasound

U.S. FOOD AND DRUG ADMINISTRATION (FDA) Echocardiograms are diagnostic procedures and are not subject to FDA regulation. Echocardiography equipment is regulated by the FDA but products are too numerous to list. See the following Web site for more information (use product code DXK, IYN, IYO or ITX). Available at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed March 21, 2010.

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APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. This list of codes may not be all inclusive. CPT® Code 93303 93304 93306 Description Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study 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 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

CPT® is a registered trademark of the American Medical Association.

93307 93308

Medically necessary ICD-9 Codes 164.1 212.7 238.8 394.0 394.1 394.2 394.9 395.0 395.1 395.2 395.9 396.0 396.1 396.2 396.3 396.8 396.9 397.0 397.1 397.9 398.0

Description Malignant neoplasm of heart Benign neoplasm of heart Neoplasm of uncertain behavior of other specified sites Mitral stenosis Rheumatic mitral insufficiency Mitral stenosis with insufficiency Other and unspecified mitral valve diseases Rheumatic aortic stenosis Rheumatic aortic insufficiency Rheumatic aortic stenosis with insufficiency Other and unspecified rheumatic aortic diseases Mitral valve stenosis and aortic valve stenosis Mitral valve stenosis and aortic valve insufficiency Mitral valve insufficiency and aortic valve stenosis Mitral valve insufficiency and aortic valve insufficiency Multiple involvement of mitral and aortic valves Unspecified mitral and aortic valve diseases Diseases of tricuspid valve Rheumatic diseases of pulmonary valve Rheumatic diseases of endocardium, valve unspecified Rheumatic myocarditis

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Medically necessary ICD-9 Codes 402.00 402.01 402.10 402.11 402.90 402.91 410.00 410.01 410.02 410.10 410.11 410.12 410.20 410.21 410.22 410.30 410.31 410.32 410.40 410.41 410.42 410.50 410.51 410.52 410.60 410.61 410.62 410.70 410.71 410.72 410.80 410.81

Description Malignant hypertensive heart disease without heart failure Malignant hypertensive heart disease with heart failure Benign hypertensive heart disease without heart failure Benign hypertensive heart disease with heart failure Unspecified hypertensive heart disease without heart failure Unspecified hypertensive heart disease with heart failure Acute myocardial infarction of anterolateral wall, episode of care unspecified Acute myocardial infarction of anterolateral wall, initial episode of care Acute myocardial infarction of anterolateral wall, subsequent episode of care Acute myocardial infarction of other anterior wall, episode of care unspecified Acute myocardial infarction of other anterior wall, initial episode of care Acute myocardial infarction of other anterior wall, subsequent episode of care Acute myocardial infarction of inferolateral wall, episode of care unspecified Acute myocardial infarction of inferolateral wall, initial episode of care Acute myocardial infarction of inferolateral wall, subsequent episode of care Acute myocardial infarction of inferoposterior wall, episode of care unspecified Acute myocardial infarction of inferoposterior wall, initial episode of care Acute myocardial infarction of inferoposterior wall, subsequent episode of care Acute myocardial infarction of other inferior wall, episode of care unspecified Acute myocardial infarction of other inferior wall, initial episode of care Acute myocardial infarction of other inferior wall, subsequent episode of care Acute myocardial infarction of other lateral wall, episode of care unspecified Acute myocardial infarction of other lateral wall, initial episode of care Acute myocardial infarction of other lateral wall, subsequent episode of care Acute myocardial infarction, true posterior wall infarction, episode of care unspecified Acute myocardial infarction, true posterior wall infarction, initial episode of care Acute myocardial infarction, true posterior wall infarction, subsequent episode of care Acute myocardial infarction, subendocardial infarction, episode of care unspecified Acute myocardial infarction, subendocardial infarction, initial episode of care Acute myocardial infarction, subendocardial infarction, subsequent episode of care Acute myocardial infarction of other specified sites, episode of care unspecified Acute myocardial infarction of other specified sites, initial episode of care

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Medically necessary ICD-9 Codes 410.82 410.90 410.91 410.92 411.0 411.1 411.81 411.89 412 413.0 413.1 413.9 414.00 414.01 414.02 414.03 414.04 414.05 414.06 414.07 414.10 414.11 414.12 414.19 414.8 415.0 415.11 415.19 416.0 416.1 416.8 416.9 417.0 417.1 417.8 417.9 420.0 420.90 420.91 420.99

Description Acute myocardial infarction of other specified sites, subsequent episode of care Acute myocardial infarction, unspecified site, episode of care unspecified Acute myocardial infarction, unspecified site, initial episode of care Acute myocardial infarction, unspecified site, subsequent episode of care Postmyocardial infarction syndrome Intermediate coronary syndrome Acute coronary occlusion without myocardial infarction Other acute and subacute form of ischemic heart disease Old myocardial infarction Angina decubitus Prinzmetal angina Other and unspecified angina pectoris Coronary atherosclerosis of unspecified type of vessel, native or graft Coronary atherosclerosis of native coronary artery Coronary atherosclerosis of autologous vein bypass graft Coronary atherosclerosis of nonautologous biological bypass graft Coronary atherosclerosis of artery bypass graft Coronary atherosclerosis of unspecified type of bypass graft Coronary atherosclerosis, of native coronary artery of transplanted heart Coronary atherosclerosis, Of bypass graft (artery) (vein) of transplanted heart Aneurysm of heart Aneurysm of coronary vessels Dissection of coronary artery Other aneurysm of heart Other specified forms of chronic ischemic heart disease Acute cor pulmonale Iatrogenic pulmonary embolism and infarction Other pulmonary embolism and infarction Primary pulmonary hypertension Kyphoscoliotic heart disease Other chronic pulmonary heart diseases Unspecified chronic pulmonary heart disease Arteriovenous fistula of pulmonary vessels Aneurysm of pulmonary artery Other specified disease of pulmonary circulation Unspecified disease of pulmonary circulation Acute pericarditis in diseases classified elsewhere Unspecified acute pericarditis Acute idiopathic pericarditis Other acute pericarditis

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Medically necessary ICD-9 Codes 421.0 421.1 421.9 423.0 423.1 423.2 423.8 423.9 424.0 424.1 424.2 424.3 424.90 424.91 424.99 425.0 425.1 425.2 425.3 425.4 425.5 425.7 425.8 425.9 426.0 426.10 426.11 426.12 426.13 426.2 426.3 426.4 426.50 426.51 426.52 426.53 426.54 426.6 426.7 426.81 426.82

Description Acute and subacute bacterial endocarditis Acute and subacute infective endocarditis in diseases classified elsewhere Unspecified acute endocarditis Hemopericardium Adhesive pericarditis Constrictive pericarditis Other specified diseases of pericardium Unspecified disease of pericardium Mitral valve disorders Aortic valve disorders Tricuspid valve disorders, specified as nonrheumatic Pulmonary valve disorders Endocarditis, valve unspecified, unspecified cause Endocarditis in diseases classified elsewhere Other endocarditis, valve unspecified Endomyocardial fibrosis Hypertrophic obstructive cardiomyopathy Obscure cardiomyopathy of Africa Endocardial fibroelastosis Other primary cardiomyopathies Alcoholic cardiomyopathy Nutritional and metabolic cardiomyopathy Cardiomyopathy in other diseases classified elsewhere Unspecified secondary cardiomyopathy Atrioventricular block, complete Unspecified atrioventricular block First degree atrioventricular block Mobitz (type) II atrioventricular block Other second degree atrioventricular block Left bundle branch hemiblock Other left bundle branch block Right bundle branch block Unspecified bundle branch block Right bundle branch block and left posterior fascicular block Right bundle branch block and left anterior fascicular block Other bilateral bundle branch block Trifascicular block Other heart block Anomalous atrioventricular excitation Lown-Ganong-Levine syndrome Long QT syndrome

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Medically necessary ICD-9 Codes 426.89 426.9 427.0 427.1 427.2 427.31 427.32 427.41 427.42 427.5 427.60 427.61 427.69 427.81 427.89 427.9 428.0 428.1 428.20 428.21 428.22 428.23 428.30 428.31 428.32 428.33 428.40 428.41 428.42 428.43 428.9 429.3 429.71 429.79 429.81 429.89 435.0 435.1 435.3 435.8 435.9

Description Other specified conduction disorder Unspecified conduction disorder Paroxysmal supraventricular tachycardia Paroxysmal ventricular tachycardia Unspecified paroxysmal tachycardia Atrial fibrillation Atrial flutter Ventricular fibrillation Ventricular flutter Cardiac arrest Unspecified premature beats Supraventricular premature beats Other premature beats Sinoatrial node dysfunction Other specified cardiac dysrhythmias Unspecified cardiac dysrhythmia Congestive heart failure, unspecified Left heart failure Unspecified systolic heart failure Acute systolic heart failure Chronic systolic heart failure Acute on chronic systolic heart failure Unspecified diastolic heart failure Acute diastolic heart failure Chronic diastolic heart failure Acute on chronic diastolic heart failure Unspecified combined systolic and diastolic heart failure Acute combined systolic and diastolic heart failure Chronic combined systolic and diastolic heart failure Acute on chronic combined systolic and diastolic heart failure Unspecified heart failure Cardiomegaly Acquired cardiac septal defect Other certain sequelae of myocardial infarction, not elsewhere classified Other disorders of papillary muscle Other ill-defined heart disease Basilar artery syndrome Vertebral artery syndrome Vertebrobasilar artery syndrome Other specified transient cerebral ischemias Unspecified transient cerebral ischemia

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Medically necessary ICD-9 Codes 436 437.7 438.11 438.12 438.20 438.21 438.22 438.30 438.31 438.32 438.40 438.41 438.42 438.6 438.7 438.81 438.82 438.83 438.84 438.85 438.89 441.01 441.03 441.1 441.2 441.6 441.7 444.0 444.1 444.21 444.22 444.81 444.89 444.9 445.01

Description Acute, but ill-defined, cerebrovascular disease Transient global amnesia Aphasia due to cerebrovascular disease Dysphasia due to cerebrovascular disease Hemiplegia affecting unspecified side due to cerebrovascular disease Hemiplegia affecting dominant side due to cerebrovascular disease Hemiplegia affecting nondominant side due to cerebrovascular disease Monoplegia of upper limb affecting unspecified side due to cerebrovascular disease Monoplegia of upper limb affecting dominant side due to cerebrovascular disease Monoplegia of upper limb affecting nondominant side due to cerebrovascular disease Monoplegia of lower limb affecting unspecified side due to cerebrovascular disease Monoplegia of lower limb affecting dominant side due to cerebrovascular disease Monoplegia of lower limb affecting nondominant side due to cerebrovascular disease Alteration of sensations as late effect of cerebrovascular disease Disturbance of vision as late effect of cerebrovascular disease Apraxia due to cerebrovascular disease Dysphagia due to cerebrovascular disease Facial weakness as late effect of cerebrovascular disease Ataxia as late effect of cerebrovascular disease Vertigo as late effect of cerebrovascular disease Other late effects of cerebrovascular disease Dissecting aortic aneurysm (any part), thoracic Dissecting aortic aneurysm (any part), thoracoabdominal Thoracic aneurysm, ruptured Thoracic aneurysm without mention of rupture Thoracoabdominal aneurysm, ruptured Thoracoabdominal aneurysm without mention of rupture Embolism and thrombosis of abdominal aorta Embolism and thrombosis of thoracic aorta Embolism and thrombosis of arteries of upper extremity Embolism and thrombosis of arteries of lower extremity Embolism and thrombosis of iliac artery Embolism and thrombosis of other specified artery Embolism and thrombosis of unspecified artery Atheroembolism of upper extremity

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Medically necessary ICD-9 Codes 445.02 445.81 445.89 453.2 458.0 458.21 458.29 458.8 458.9 511.0 511.1 511.81 511.9 514 518.81 518.82 745.0 745.10 745.11 745.12 745.19 745.2 745.3 745.4 745.5 745.60 745.61 745.69 745.7 745.8 745.9 746.00 746.01 746.02 746.09 746.1 746.2 746.3 746.4

Description Atheroembolism of lower extremity Atheroembolism of kidney Atheroembolism of other site Other venous embolism and thrombosis, of inferior vena cava Orthostatic hypotension Hypotension of hemodialysis Other iatrogenic hypotension Other specified hypotension Unspecified hypotension Pleurisy without mention of effusion or current tuberculosis Pleurisy with effusion, with mention of bacterial cause other than tuberculosis Malignant pleural effusion Unspecified pleural effusion Pulmonary congestion and hypostasis Acute respiratory failure Other pulmonary insufficiency, not elsewhere classified Bulbus cordis anomalies and anomalies of cardiac septal closure, common truncus Complete transposition of great vessels Transposition of great vessels, double outlet right ventricle Corrected transposition of great vessels Other transposition of great vessels Tetralogy of Fallot Bulbus cordis anomalies and anomalies of cardiac septal closure, common ventricle Ventricular septal defect Ostium secundum type atrial septal defect Unspecified type congenital endocardial cushion defect Ostium primum defect Other congenital endocardial cushion defect Cor biloculare Other bulbus cordis anomalies and anomalies of cardiac septal closure Unspecified congenital defect of septal closure Unspecified congenital pulmonary valve anomaly Congenital atresia of pulmonary valve Congenital stenosis of pulmonary valve Other congenital anomalies of pulmonary valve Congenital tricuspid atresia and stenosis Ebstein's anomaly Congenital stenosis of aortic valve Congenital insufficiency of aortic valve

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Medically necessary ICD-9 Codes 746.5 746.6 746.7 746.81 746.82 746.83 746.84 746.85 746.86 746.87 746.89 746.9 747.0 747.10 747.11 747.20 747.21 747.22 747.29 747.3 747.40 747.41 747.42 747.49 759.82 780.2 780.4 785.1 785.2 785.50 785.51 785.52 785.59 786.01 786.02 786.03 786.04 786.05 786.06 786.07 786.09

Description Congenital mitral stenosis Congenital mitral insufficiency Hypoplastic left heart syndrome Congenital subaortic stenosis Cor triatriatum Congenital infundibular pulmonic stenosis Congenital obstructive anomalies of heart, not elsewhere classified Congenital coronary artery anomaly Congenital heart block Congenital malposition of heart and cardiac apex Other specified congenital anomaly of heart Unspecified congenital anomaly of heart Patent ductus arteriosus Coarctation of aorta (preductal) (postductal) Congenital interruption of aortic arch Unspecified congenital anomaly of aorta Congenital anomaly of aortic arch Congenital atresia and stenosis of aorta Other congenital anomaly of aorta Congenital anomalies of pulmonary artery Congenital anomaly of great veins unspecified Total congenital anomalous pulmonary venous connection Partial congenital anomalous pulmonary venous connection Other congenital anomalies of great veins Marfan's syndrome Syncope and collapse Dizziness and giddiness Palpitations Undiagnosed cardiac murmurs Unspecified shock Cardiogenic shock Septic shock Other shock without mention of trauma Hyperventilation Orthopnea Apnea Cheyne-Stokes respiration Shortness of breath Tachypnea Wheezing Other dyspnea and respiratory abnormalities

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Medically necessary ICD-9 Codes 786.50 786.51 786.52 786.59 790.7 793.1 793.2 794.31 799.02 996.00 996.02 996.09 996.61 V15.9 V17.41 V17.49 V42.1 V42.2 V43.21 V43.22 V43.3 V45.01 V45.09 V58.11 V81.2

Description Unspecified chest pain Precordial pain Painful respiration Other chest pain Bacteremia Nonspecific (abnormal) findings on radiological and other examination of lung field Nonspecific (abnormal) findings on radiological and other examination of other intrathoracic organs Nonspecific abnormal electrocardiogram (ecg) (ekg) Hypoxemia Mechanical complication of unspecified cardiac device, implant, and graft Mechanical complication due to heart valve prosthesis Mechanical complication of cardiac device, implant, and graft, other Infection and inflammatory reaction due to cardiac device, implant, and graft Unspecified personal history presenting hazards to health Family history of sudden cardiac death [SCD] Family history of other cardiovascular diseases Heart replaced by transplant Heart valve replaced by transplant Organ or tissue replaced by other means, Heart assist device Organ or tissue replaced by other means, Fully implantable artificial heart Heart valve replaced by other means Cardiac pacemaker in situ Other specified cardiac device in situ Encounter for antineoplastic chemotherapy Screening for other and unspecified cardiovascular conditions

ICD-9 Procedure Code 88.72

Description Diagnostic ultrasound of heart

Coding Clarification Add on codes (such as 93320, 93321 or 93325) may be reported with 93303, 93304 and 93308 as defined in CPT coding guidelines. Please consult the AMA CPT coding guidelines for additional directions. This policy does not address the use of transthoracic echocardiography with a cardiac stress test; therefore, the following CPT codes do not apply: 93350, 93351 and 93352.

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REFERENCES American Academy of Pediatrics. Guidelines for Pediatric Cardiovascular Centers. Pediatrics. 2002 Mar;109(3):544-9. American College of Radiology. ACR Appropriateness Criteria (2008a). Acute Chest Pain - Low Probability of Coronary Artery Disease. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2008b). Acute Chest Pain - Suspected Aortic Dissection. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2008c). Chronic Chest Pain - High Probability of Coronary Artery Disease. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2008d). Chronic Chest Pain - Low to Intermediate Probability of Coronary Artery Disease. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2006a). Acute Chest Pain - Suspected Pulmonary Embolism. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2006b). Shortness of Breath Suspected Cardiac Origin. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

American College of Radiology. ACR Appropriateness Criteria (2006c). Suspected Bacterial Endocarditis. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010.

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American College of Radiology. ACR Appropriateness Criteria (2007). Suspected Congenital Heart Disease in the Adult. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCar diovascularImaging.aspx. Accessed March 21, 2010. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006 Aug 1;48(3):e1-148. Centers for Medicare and Medicaid Services. Palmetto GBA (01302), LCD for Echocardiography, Transthoracic and Transesophagael. (L28254). Effective September 02, 2008. Revision November 12, 2009. Centers for Medicare & Medicaid Services (CMS), Palmetto GBA (01302), LCD for Echocardiography, Transthoracic and Transesophageal (L28254) Effective: September 02, 2008. Updated: November 03, 2009. Accessed April 2010. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2003 Sep 2;108(9):1146-62. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2007 Jul 10;50(2):187-204. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2003 Jan 1;41(1):159-68. Lai WW, Geva T, Shirali GS, et al. Guidelines and standards for performance of a pediatric echocardiogram: a report from the Task Force of the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr. 2006 Dec;19(12):1413-30. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007 Mar

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27;115(12):1643-455. NHLBI [Internet]. Echocardiography. http://www.nhlbi.nih.gov/health/dci/Diseases/echo/echo_all.html. Accessed January 19, 2010. Roy PM, Colombet I, Durieux P, et al. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005 Jul 30;331(7511):259. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003 Jul;16(7):777-802.

PROTOCOL HISTORY/REVISION INFORMATION Date 05/01/2010 05/21/2010 03/20/2009 Action/Description Medical Technology Assessment Committee Corporate Medical Affairs Committee

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Microsoft Word - transthoracic_echocardiography.doc
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