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Stress Echocardiography
The following are considered medically necessary for  stress echo:

1. New, recurrent, or worsening cardiac symptoms AND any of the following:

Physical inability to perform a maximum exercise workload

A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or PCI

Syncope (i.e., no prodromal symptoms, not near syncope) in patient with high likelihood of CAD

Evidence or high suspicion of ventricular tachycardia

Age 50 years or greater and known diabetes mellitus

New or previously unrecognized uninterpretable ECG

Poorly controlled hypertension, generally, above 180 mm/Hg systolic, if the provider feels strongly that CAD needs evaluation prior to BP being controlled

ECG is uninterpretable for ischemia due to any one of the following:

Complete Left Bundle Branch Block (right bundle branch does not render ECG uninterpretable for ischemia)
Ventricular paced rhythm
Pre-excitation pattern such as Wolff-Parkinson-White
> 0.5 mm ST segment depression (NOT nonspecific ST/T wave changes)
LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria)
T wave inversion in the inferior and/or lateral leads (leads II, AVF, V5, or V6)
Patient on digitalis preparation

Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result
Patients with recent equivocal or borderline testing where ischemia remains a concern
Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study
History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD)
High pretest probability of CAD (assuming emergency evaluation and/or prompt coronary angiography not previously implemented)

2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin

3. Routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

4. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

5. Every 2 years in patients with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test

6. To assess for CAD in a patient with unexplained or drug-induced intraventricular condition disturbances

7. Prior anatomic imaging study (coronary angiogram or CCTA) to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging

8. Established CAD in a patient who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable

9. Evaluating new, recurrent, or worsening left ventricular dysfunction/CHF

10. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered

11. Pre-operative cardiac evaluation in patients undergoing non-cardiac surgery

Intermediate risk surgery (cardiac risk 1-5%) one or more cardiac risk factor(s) and inability to exercise adequately
high risk surgery (> 5% cardiac risk)

12. Asymptomatic patients with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years

13. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year

14. Patients to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc.

15. Patients with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years

16. Stress echocardiography will be considered reasonable and necessary for the evaluation of valvular heart disease and detection and management of occult pulmonary hypertension.

Transthoracic Echocardiography

A transthoracic echocardiography (TTE) will be considered medically reasonable and necessary for the following conditions:

1. Native Valvular Heart Disease
2. Prosthetic Heart Valves (Mechanical and Bio-prostheses)
3. Endocarditis
4. Ventricular Function and Cardiomyopathies
5. Acute Myocardial Infarction and Coronary Insufficiency
6. Hypertensive Cardiovascular Disease
7. Cardiac Transplant and Rejection Monitoring
8. Exposure to Cardiotoxic Agents (Chemotherapeutic and External)
9. Pericardial Disease
10. Congenital Heart Disease
11. Cardiac Tumors and Masses
12. Critically Ill and Trauma Patients
13. Suspected Cardiac Thrombi and Embolic Sources
14. Contrast echocardiography
15. Diseases of Aorta

Transesophageal Echocardiography

Transesophageal echocardiogram will be considered medically necessary in any of the following circumstances:

Examination of prosthetic heart valves, primarily mitral
Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions. TEE may complement transthoracic echocardiography particularly to assess for left atrial thrombus.
Detection of:

aortic dissection
atrial septal defect
congenital heart disease
embolism or thrombosis, primarily involving left atrium
intracardiac foreign bodies, tumors or masses
mitral valve regurgitation
vegetative endocarditis

Intra-operative guide to left ventricular function
Inadequacy of transthoracic echo due to:

chest wall deformity, COPD
open heart or chest surgery
chest trauma

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