Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of chronic pain, including, but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia, is considered investigational.

Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of psychiatric disorders, including but not limited to depression and obsessive-compulsive disorder, is considered investigational.

Transcatheter embolization of uterine arteries as a treatment of uterine fibroids or as a treatment of postpartum uterine hemorrhage may be considered medically necessary.

One repeat transcatheter embolization of uterine arteries to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization may be considered medically necessary (see Policy Guidelines section).

Transcatheter embolization for the management of all other indications, including cervical ectopic pregnancy, uterine arteriovenous malformation, and adenomyosis is considered investigational.

Laparoscopic or transcervical radiofrequency ablation (RFA) as a treatment of symptomatic uterine fibroids is considered medically necessary in women 18 years and older when ALL of the following conditions are met:

Evidence of uterine fibroids via ultrasound that are less than 10 cm in diameter for laparoscopic RFA with Acessa or 7 cm for transcervical RFA with Sonata; AND

Patient desires a uterine-sparing treatment approach or is ineligible for hysterectomy or other uterine-sparing alternatives to RFA (e.g., laparoscopic myomectomy, uterine artery embolization [UAE]) (see Policy Guidelines); AND

Patient has experienced at least 1 of the following symptoms that are a direct result of the fibroid(s):

Menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia (see Policy Guidelines);

Pelvic pain or pressure;

Urinary symptoms (e.g., urinary frequency, urgency) related to bulk compression of the bladder;

Gastrointestinal symptoms related to bulk compression of the bowel (e.g., constipation, bloating);

Dyspareunia (painful or difficult sexual relations).

Other laparoscopic, transcervical, or percutaneous techniques for myolysis of uterine fibroids, including use of laser or bipolar needles, cryomyolysis, and magnetic resonance imaging-guided laser ablation, are considered investigational.

La oclusión histeroscópica de los tubos de Falopio como método de esterilización permanente se considera para pago.

Endovascular occlusion of the ovarian vein and internal iliac veins is considered investigational as a treatment of pelvic congestion syndrome.

For individuals with a singleton pregnancy and prior spontaneous preterm birth before 37 weeks of gestation, the following may be considered medically necessary:

Weekly injections of 17α-hydroxyprogesterone caproate, initiated between 16 and 20 weeks of gestation, and continued until 36 weeks 6 days.

Daily vaginal progesterone between 24 and 34 weeks of gestation.

For individuals with a singleton pregnancy and a short cervix (<20 mm), the following may be considered medically necessary: Daily vaginal progesterone initiated between 20 and 23 weeks 6 days of gestation and continued until 36 weeks 6 days. Progesterone therapy as a technique to prevent preterm delivery is considered investigational in pregnant individuals with other risk factors for preterm delivery, including but not limited to: twin or multiple gestations; prior episode of preterm labor in current pregnancy (ie, progesterone therapy in conjunction with tocolysis or following successful tocolysis); positive test for cervicovaginal fetal fibronectin; in conjunction with or following cervical cerclage; uterine anomaly.

La ablación del endometrio utilizando cualquiera de los dispositivos aprobados por FDA se considera para pago en mujeres con menorragia que no son candidatas a terapia o que no han respondido a terapia con hormonas o dilatación y curetage donde se ha descartado malignidad. No se considera para pago para cualquier otra indicación.

La prueba del primer trimestre para la detección del síndrome de Down que incorpora marcadores séricos maternos y medición de la translucencia nucal fetal se considera para pago para las mujeres que desean estar debidamente asesoradas y les interesa conocer la información sobre el riesgo de tener un hijo con síndrome de Down.
No se considera para pago el cernimiento de Sindrome de Down en el primer trimestre, utilizando solamente la medida de traslucencia nucal.
El cernimiento que utiliza la evaluación de la translucencia del tabique nasal, no se considera para pago.

Ablación laparoscópica del nervio uterino (LU) y la Neurectomia Presacral laparoscópica (LPSN) no se consideran para pago como tratamiento de dismenorrea primaria o secundaria. Los estudios publicados no permiten conclusiones científicas a largo plazo en pacientes de dismenorrea primaria tratados con esta metodología.

The robot-assisted gynecologic surgery (robotic surgery) is considered a modality of conventional laparoscopic gynecological surgery currently paid. It is not considered additional payment to those established for standard procedure.

Ultrasonographic evaluation of the fetomaternal complex in the different stages of pregnancy is considered clinically indicated and medically necessary.

Intrauterine devices are considered medically necessary in the prevention of pregnancy.

Reducción de líquido amniótico y/o terapia de coagulación por ablación con láser se considera para pago como tratamiento del síndrome de transfusión de feto a feto. La terapia por láser puede ser precedida por angiografía, y/o sonografía con doppler para identificar los vasos sanguíneos placentarios a ser tratados.

Estos servicios son altamente especializados y se cubrirán solamente en los centros médicos supraterciario, altamente especializados.

Vesicoamniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in fetuses under the following conditions:

Evidence of hydronephrosis due to bilateral urinary tract obstruction AND
Progressive oligohydramnios AND
Adequate renal function AND
No other lethal abnormalities or chromosomal defects.

Open in utero resection of malformed pulmonary tissue or placement of a thoracoamniotic shunt may be considered medically necessary under the following conditions:

Congenital cystic adenomatoid malformation or bronchopulmonary sequestration is identified; AND
The fetus is at 32 weeks of gestation or less AND
There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe preeclampsia (ie, the maternal mirror syndrome) in the mother.

In utero removal of sacrococcygeal teratoma may be considered medically necessary under the following conditions:

The fetus is at 32 weeks of gestation or less AND
There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe preeclampsia (ie, maternal mirror syndrome) in the mother.

In utero repair of myelomeningocele may be considered medically necessary under the following conditions:

The fetus is at less than 26 weeks of gestation AND
Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.

In utero repair of myelomeningocele is considered investigational in the following situations:

Fetal anomaly unrelated to myelomeningocele OR
Severe kyphosis OR
Risk of preterm birth (eg, short cervix or previous preterm birth) OR
Maternal body mass index of 35 kg/m2 or more.

All other applications of fetal surgery are investigational, including but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.

Gender affirming surgery is considered medically necessary for the treatment of individuals with gender dysphoria when the following criteria is met:

1. Reached at least 21 years of age, and
2. Insured must have the ability to make a fully informed decision and give consent for treatment, and
3. Have been diagnosed with persistent gender dysphoria,
4. Lived continuously for at least 6 months in the gender role (real-life experiences) that is consistent with the preferred gender, without periods of time to return to the original sex of the person, and
5. Completed at least 12 months of continuous hormonal of any male to female (MTF) or female to male (FTM)* and
6. Subjected to a urological examination to identify and treat genitourinary anomalies**, and
7. One referral from a qualified health professional is needed for surgery.

*Note: A trial of hormone therapy is not required to qualify for a mastectomy.
**Note: Only recommended for genitourinary surgeries
The following gender affirming services are considered medically necessary for a person who has met the selection criteria mentioned above:
Male to female
• Clitoroplasty
• Coloproctostomy
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Perineoplasty
• Investment of penile skin
• Repair of the introit
• Urethroplasty
• Vaginoplasty with vaginal construction with graft, and/or vulvoplasty
• Total breast reconstruction
• Voice modification (surgery or therapy)
• Elimination of hair on thorax
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
Female to male

• Hysterectomy
• Metoidioplasty
• Phalloplasty
• The placement (and removal if necessary) of an implantable erectile prosthesis
• The placement of testicular prostheses
• Salpingo-oophorectomy
• Subcutaneous mastectomy
• Vaginectomy, also known as colpectomy
• Vulvectomy
• Urethroplasty
• Urethromeatoplastia
• Scrotoplasty
• Testicular expanders
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
The following procedures or services are considered cosmetic or not medically necessary when used to improve the gender of a person who intends to undergo, or has undergone gender affirming surgery, including but not limited to:
• Abdominoplasty
• Blepharoplasty
• Brow lift
• Cheek implants
• Nose or chin implants
• Collagen injections
• Facelift
• Facial reconstruction bone / sculpture / reduction, including shortening of the jaw
• Forehead or conturing
• Hair transplant
• Reducing lips or lip augmentation
• Liposuction or body conturing
• Rhytidectomy
• Reduction or shaving trachea, thyroid chondroplasty
• Elimination of redundant skin
• Rhinoplasty
• Skin rejuvenation
• Voice modulation theraphy
Psychotherapy is not necessary for the gender affirming surgery, except when the initial assessment of mental health professional recommends psychotherapy that specifies treatment goals, estimates of frequency and duration throughout the real life experience.

Evaluation and treatment of infertility is considered medicaly necessary and maybe submitted for reinbursement as per policy coverage.

Autonomic nervous system testing, consisting of a battery of tests in several domains (see Policy Guidelines section), may be considered medically necessary when the following criteria are met:

Signs and/or symptoms of autonomic dysfunction are present; AND

A definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone; AND

Diagnosis of the suspected autonomic disorder will lead to a change in management or will eliminate the need for further testing.

Autonomic nervous system testing is considered investigational in all other situations when criteria are not met, including but not limited to the evaluation of the following conditions:

Chronic fatigue syndrome,

Fibromyalgia,

Anxiety and other psychologic disorders,

Sleep apnea,

Allergic conditions,

Hypertension,

Screening of asymptomatic individuals, and

Monitoring progression of disease or response to treatment.

Autonomic nervous system testing using portable automated devices is considered investigational for all indications (see Policy Guidelines section).

Neuropsychological tests are considered for payment in the following situations if they are administered by a neuropsychologist as ordered by a neurologist:

1. Establish a differential diagnosis between organic and functional pathology.

2. Evaluation of dementia vs. Pseudodementia

3. Differentiate epilepsy from pseudoconvulsions.

4. Differentiate sequelae from brain trauma simulation («malingering»).

Los servicios de cuidado pediátrico crítico se proveen (pero no están limitados) a pacientes con fallo en el sistema nervioso central, fallo circulatorio, condiciones similares, shock, fallo renal, hepático o respiratorio, complicaciones postoperatorias o infecciones incontrolables.
Los siguientes servicios están incluidos en los códigos 99468, 99469, 99471-99476:
La interpretación y monitoreo de medidas de débito cardiaco, gases arteriales o saturación de oxígeno, función pulmonar, signos vitales, ECG, datos hematológicos y cualquier dato guardado en la computadora;

Evaluación de rayos X;

Supervisión de mantenimiento de nutrición parenteral y enteral;

Supervisión oral o nasogástrica.

Manejo de ventilador o CPAP;

Cateterizaciones umbilicales, centrales o periferales;

Punción lumbar, aspiraciones suprapúbicas de vejiga;

Cateterizaciones de vejiga;

Administración de medicamentos y fluidos intravasculares;

Transfusiones de sangre o sus componentes;

Servicios de detención prolongada;

Cualquier otro servicio esencial para el cuidado crítico de treinta minutos o menos de duración deberá facturarse por los códigos de E/M apropiados.

The Neonatal Hearing Screening program establishes performing hearing screening tests on all infants before leaving the Newborn Rooms of the hospital.

Las pruebas de función pulmonar en infantes y niños no se consideran para pago ya que su utilidad no ha sido establecida.

The patient receives medical evaluation and management services. These services involve a variety of unique, medical management responsibilities for psychiatric patients, such as:

• medical evaluations

(Eg tests for assessing comorbidity of mental condition, drug interaction and physical examination).

• medication management, when indicated.

• medical orders

• interpretation of laboratories or

• any other diagnostic study and

• observation

This visit must be clearly documented in the file.

90785

Interactive: this concept includes and recognizes the effort required for situations where there is: difficulty of communication for different types of patients and situations that represent important factors that complicate and increase the intensity of the primary psychiatric process.

90791

This service is paid once every three years, if the patient has not had

other services with the provider or another participant of the group during that period of time.

During the initial examination code 90791; the provider conducts an interview with the patient to acquire a complete medical history (including past, family, social) and psychiatric history, mental status, and disposition to obtain a diagnosable disorder. In some cases, the initial diagnostic interview (code 90791) may include: communication with family or other sources, and in certain circumstances, it may also be necessary that other informants will be seen in place of the patient. The extent of mental status evaluation depends on the patient’s condition. There are some symptoms of psychopathology that the provider will study to determine the initial treatment plan, such as, but not limited to, the patient’s appearance.

90792

This service is paid once a year.

The code 90792; in addition to including (such as code 90791) history and mental status of review and review and / or diagnostic study orders as necessary, recommendations (includes communications with family or other sources). It also includes the psychiatric examination (CMS), prescription of medications when appropriate and any order or reading of laboratory tests.

It is paid more than once per patient when an evaluation is carried out separating a different diagnosis with the patient and other informants.

It is not paid on the same day as a psychotherapy, nor on the same day as an evaluation and management (E / M codes)

When reporting the add-on codes, the real time spent in the meeting must be taken into consideration. Example:

– from 16 to 35 minutes the codes to report are 90832-90833

– from 38-52 minutes the codes to report are 90834-90836

– of 53 minutes or more the codes to report are 90837 or 90838 according to

Apply

When an evaluation and management (E / M) is carried out in conjunction with the same-day psychotherapy by the same physician (90833, 90836, 90838), the evaluation and management service (E / M) documentation must identify a significant encounter separate from psychotherapy. Please refer to the assessment and management (E / M) criteria reported in the Evaluation and Management Section of the Triple S-Health Participant Payment Policy Manual. Clear documentation of assessment and management services is recommended in a separate section within the patient’s record as these services are auditable

Debe haber una nota separada en el expediente, donde se identifique la relación de la persona con el paciente, (padre, madre, esposo, hijo, vecino, etc.) y el contenido de la reunión.
La mera presencia física de una persona «A» durante el tratamiento de otra persona «B», no constituyen una visita colateral.
La visita colateral es aquella que ocurre cuando a la persona «A» se le dedica tiempo separado del tiempo de la terapia de la persona «B» con el fin de compartir información esencial al cuidado de la persona «B» quién es el paciente.
Este procedimiento deberá estar claramente documentado en el expediente.

Opioid antagonists under heavy sedation or anesthesia are considered investigational as a technique for opioid detoxification (ie, ultrarapid detoxification).

La terapia electroconvulsiva se considera para pago como tratamiento para la depresión mayor, desórdenes bipolares, catatonia, y esquizofrenia que no han respondido a otros tratamientos convencionales
La administración de esta terapia deberá cumplir con las siguientes disposiciones:
La Ley 408 del 2 de octubre de 2000, conocida como la Ley de Salud Mental de Puerto Rico

El Reglamento para la implantación de la Ley de Salud Mental de Puerto Rico, tanto para personas Adultas (Capítulo VI, Sistema de Cuidado de Salud Mental Para Adultos, Articulo F.) como para el caso de Menores de Edad ( Capitulo VI Articulo J )

Adultos
ARTICULO F. TERAPIA ELECTROCONVULSIVA
Sección 1. Ningún adulto recibirá tratamiento de terapia electroconvulsiva sin que medie su consentimiento y autorización expresa previa por escrito.
Sección 2. El adulto a quien se le considere para recibir tratamiento de terapia electroconvulsiva y su tutor, si lo hubiere, será notificado por lo menos cuarenta y ocho (48) horas anteriores al tratamiento.
Sección 3. Todo adulto tendrá el derecho a rehusar este tratamiento en cualquier momento después de haber aceptado el mismo.
Sección 4. Toda entidad proveedora de servicios en salud mental que ofrezca Ia modalidad de terapia electroconvulsiva, tendrá un protocolo que incorpore los estándares aceptados por la “American Psychiatric Association” (APA) y las entidades que regulan la administración de dicha terapia. Dicho protocolo será revisado anualmente.
Sección 5. Será responsabilidad de la entidad proveedora de servicios de salud mental mantenerse actualizada sobre los adelantos científicos que puedan alterar los procedimientos o administración de esta modalidad de tratamiento.
Sección 6. Tratamiento involuntario de Terapia Electroconvulsiva.
6.1 En el caso de que este tratamiento sea indicado para el adulto, pero que por su condición no pueda consentir, y no tenga tutor asignado legalmente, será necesario celebrar una vista para que el tribunal determine si procede o no el tratamiento y emita una orden a dichos efectos.
6.2 Dicha vista será celebrada sumariamente en el tribunal más cercano a la institución. La cual será celebrada dentro de las (8) ocho horas siguientes a la petición, cuando se establezca bajo juramento que el no ofrecer esta modalidad de tratamiento podrá resultar en daño inminente a la persona que recibe servicios de salud mental.
6.3 Se requerirá prueba clara y convincente a los efectos de demostrar al Tribunal que la terapia electroconvulsiva es la modalidad adecuada.
Sección 7. Todo profesional de la salud mental facultado por este reglamento para participar en el proceso de la administración de la terapia electroconvulsiva deberá completar un adiestramiento sobre el uso y aplicación de esta modalidad terapéutica, y presentar evidencia del certificado correspondiente.
7.1 El adiestramiento podrá ser ofrecido por cualquier entidad debidamente acreditada por el American Psychiatric Association, para ofrecer adiestramientos sobre esta modalidad terapéutica. Los certificados expedidos por concepto de adiestramientos relacionados, tendrán una vigencia de dos (2) años.
Menores

Triple – S will cover for payment the following services as medically necessary in the evaluation of a known or suspected ASD case:

·         Audiological Evaluation

·         Behavior Evaluation including psychiatric test

·         Electroencephalograms when seizure states are suspected

·         Speech and language evaluation by a speech pathologist

·         Lead screening

·         Medical evaluation including history and physical exam

·         Specific screening for Autism

·         Neuroimaging studies when the child is a candidate for surgical intervention such as surgery for epilepsy

·         Occupational therapy and/or physical therapy when sensory motor deficiencies or motor planning is present

·         Sensorial Integrated Treatment

·         Quantitative testing for amino acids to determine phenylketonuria

Triple – S will cover for payment these services when any of the following criteria is met:

·         Loss of language or social skills at any age

·         Absence of babbling by 12 months of age

·         Absence of gestures (pointing) by 12 months of age

·         Absence of pronouncing ONE word by 16 months of age

·         Absence of pronouncing TWO words in a phrase by 24 months of age

Triple-S will cover for payment behavioral treatment in cases of ASD when all of the following criteria are met:

·         Criteria for ASD according to “Diagnostic and Statistical Manual of Mental Health Disorders” Fifth Edition, Text Revision (DSM-V-TR).

·         Services are appropriate in type, frequency, extent, site and duration

·         Services are provided by a professional staff in the behavior area

·         When it is expected that the therapy produces a measurable improvement

Triple-S will cover for payment, genetic testing for the following situations:

·         Genetic testing for mutations in the FMR1gene when the Fragile-X syndrome is suspected in presence of dysmorphologic characteristics or mental retardation.

·          Genetic testing for mutations in the MECP2 gene when presence of Rett’s syndrome is suspected.

·         Pre-pregnancy genetic testing to determine presence of a carrier when there is positive family history of the Fragile-X syndrome or Rett’s syndrome in a relative of first or second line of consanguinity.

·         Prenatal tests to the fetus (amniocentesis or biopsy of the chorionic villus sampling (CVS) when any parent is a known carrier of the FMR1 or MECP2 genes.

As expressed in the Welfare, Integration and Development of Individuals with Autism Law (BIDA in Spanish), Law No. 220 – 2012, of September 4, 2012 *, cognitive rehabilitation is considered for payment under autism conditions.

Triple-S does not consider for payment:

·         Allergy tests

·         Antibodies tests for “Celiac Disease”

·         Peroxidase erythrocyte glutathione studies

·         Evoked potentials

·         Hair analysis

·         Heavy metals tests

·         Immunological or neurochemical tests

·         Intestinal permeability tests

·         Magnetoencephalography

·         Vitamin levels

·         Lactate and pyruvate tests

·         Tests of Chelation for mercury

·         Urinary tests for peptides

Triple-S does not consider for payment the following therapies:

·         Acupuncture

·         Art Therapy

·         Auditory interaction training

·         Alternate communication

·         Chelation Therapy

·         Craniosacral Therapy

·         Dietary and Nutritional Intervention

·         Feedback

·         Equestrian Therapy

·         Facilitated Communication

·         Hyperbaric Oxygen Therapy

·         Immunoglobulin

·         Music therapy

·         Recreational Therapy

·         Secretin Infusion

·         Vision Therapy

Psychiatric Services are medically necessary

Cervical cerclage is medically necessary for the treatment of an incompetent cervix, which is one that has been associated with previous spontaneous abortions or miscarriages.

Home uterine activity monitoring through a monitoring device and/or daily nursing contact is considered not medically necessary.

Conditions for which antepartum evaluation is considered for payment:

Decrease in fetal movements
Maternal hypertensive states
Diabetes Mellitus (insulin dependent)
Oligohydramnios or polyhydramnios
Intrauterine fetal growth retardation
Past term pregnancy
Multiple pregnancy with fetal growth disparity
Fetal growth restriction
Alloinmunization
Previous fetal demise
Decreased fetal activity
Preterm labor witk rupture of menbranes
Antiphospholipid syndrome
Sickle cel disease

• In certain high-risk conditions, testing can start as early as 28 weeks. The implications of a non-reassuring test are unclear before 28 weeks.

• When the condition causing the test persists, a reassuring («reactive») test may be repeated periodically until delivery. An interval of 7 days between tests is considered adequate in the presence of reassuring («reactive») results. This will give 8 false negatives/1000 tests. With certain maternal complications, a shorter interval may be considered.

Therapeutic radiopharmaceuticals for prostate cancer using Lutetium (Lu) 177 vipivotide tetraxetan (Lu-177-PSMA-617), may be considered medically necessary for the treatment of adults with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC) and with 1 or more PSMA-positive lesions and/or metastatic disease that is predominately PSMA-positive and with no dominant PSMA-negative metastatic lesions, who have been treated previously with androgen receptor-directed therapy and a taxane-based chemotherapy.

Therapeutic radiopharmaceuticals for prostate cancer using Lu-177-PSMA-617 is considered investigational for the treatment of prostate cancer when the above criteria are not met.

The use of EndeavorRx is considered investigational for all indications including attention-deficit/hyperactivity disorder.

Digital health therapies for individuals with substance use disorders are considered investigational.

Quantitative electroencephalographic-based assessment of the theta/beta ratio is considered investigational as a diagnostic aid for attention-deficit/hyperactivity disorder.

Psychiatric services in the home will be covered for payment when they comply with what is expressed in the summary.

El tratamiento de Síndrome de obstrucción en el conducto aéreo superior con CPAP (continuous positive airway pressure), BPAP (bi-level positive airway pressure) o APAP (auti-titrating positive airway pressue) no procede para pago. La evidencia publicada es escasa y no existe manera de estratificar UARS con polisomnografias.
Tratamiento para el ronquido no se considera para pago, por método alguno, en ausencia de un diagnostico confirmado de apnea del sueño obstructiva (OSA).

La espirometría casera o espirometría ambulatoria no se considera para pago. La escasez de datos no permiten llegar a conclusiones científicas sobre el monitoreo ambulatorio de FEV-1 y FEC. Específicamente, no hay datos adecuados que determinen como reducciones en FEV-1 y FEC se pueden relacionar a los síntomas clínicos y como ésta información puede usarse para determinar la necesidad de una biopsia.

Se considera para pago en pacientes adultos con:
Enfisema, que tengan una deficiencia de -1-AT demostrada por niveles sanguíneos de menos de 50 mg/dL en la población de fenotipos ZZ.

FEV1/FVC<70% Paciente no debe ser fumador Estos servicios no se consideran para pago en pacientes con enfisema donde no se documente la deficiencia de Alfa-1-Antitripsina (-1-AT).

Esta medición se considera para pago si se realiza en pacientes:
Cuya saturación de oxígeno está comprometida durante las horas del sueño y se está evaluando la eficacia de la ventilación continua con presión positiva de aire (CPAP, por sus siglas en inglés).
Sólo se cubre una oximetría continua durante la evaluación del CPAP.
La oximetría continua está cubierta cuando se requieren para el tratamiento en el hogar.
En las instalaciones hospitalarias y de cirugías ambulatorias, está incluido dentro del «per diem».

For patients with chronic obstructive pulmonary disease (COPD) without significant hypercapnia (PaCO2 < 52 mmHg) and with obstructive sleep apnea, see policy 2.01.18 (Diagnosis of Obstructive Sleep Apnea Syndrome) and 8.01.64 (Medical Management of Obstructive Sleep Apnea Syndrome). Nocturnal bilevel positive airway pressure (BPAP) with backup rate may be considered medically necessary for individuals with COPD and chronic respiratory failure (see Policy Guidelines) who meet either of the following: Chronic stable daytime (awake) hypercapnia (PaCO2>52 mmHg) OR

Daytime (awake) hypercapnia (PaCO2>52 mmHg) at least 2 weeks after discharge from the hospital for an acute exacerbation with decompensated respiratory acidosis.

Non-invasive home mechanical ventilation may be considered medically necessary for individuals with COPD who meet the following criteria:

Qualify for a BPAP device AND meet at least one of the following:

Higher pressure is needed to reduce hypercapnia than can be achieved with a bilevel device during titration (typically >25cm H2O); OR

Severe hypoxemia requiring fraction of inspired oxygen (FIO2) >40% or >5 L/min; OR

Daytime use (battery operated unit) is required to reduce hypercapnia.

Individuals with COPD who are started on BPAP at discharge from hospitalization may continue for up to 3 months to provide time to stabilize and complete reevaluation.

Non-invasive positive airway pressure for COPD is considered investigational under all other conditions.

Bilevel positive airway pressure may be considered medically necessary for individuals with thoracic restrictive disorders due to neuromuscular disease who meet any of the following:

Pulmonary function tests:

Spirometry (upright or supine) with vital capacity <50% predicted or <80% predicted with associated symptoms (orthopnea, dyspnea, morning headaches, excessive daytime sleepiness, or unrefreshing sleep); OR Maximal inspiratory pressure <60 cm H2O or maximum expiratory pressure (MEP) <40 cm H2O; OR Peak cough flow (PCF) <270 L/min for age ≥12 years or PCF <5th percentile for age <12 years; OR Sniff nasal inspiratory pressure (SNIP) <70 cm H2O in males, SNIP <60 cmH2O in females for age ≥12 years. Hypercapnia Chronic stable daytime (awake) hypercapnia with PaCO2 ≥45 mmHg (capillary blood gas can be used in children); OR Venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2, ≥50 mmHg; OR Hypoxia Overnight oximetry in-laboratory or home sleep test with saturation <88% for 5 minutes; Overnight oximetry: SpO2 ≤ 90% for ≥ 2% of sleep time. Non-invasive home mechanical ventilation may be considered medically necessary for individuals with thoracic restrictive disorders due to neuromuscular disease who meet the following: Qualify for a BPAP device; AND BPAP fails; OR Have extreme loss in function with vital capacity <30%; OR Non-invasive ventilation is needed for >10 hours per day; OR

Severe breathlessness (e.g., with speaking at rest); OR

Worsening daytime hypercapnia with need for mouthpiece ventilation; OR

Daytime use (battery operated unit) is required to reduce hypercapnia or dyspnea.

Bilevel positive airway pressure may be considered medically necessary for individuals with hypoventilation syndromes who meet the following criteria:

Awake or sleep hypoventilation with hypercapnia (one of the following is met):

Awake hypoventilation with chronic stable daytime (awake) hypercapnia (PaCO2 ≥ 45 mmHg); OR

Venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2 ≥50 mmHg; OR

Sleep hypoventilation with hypercapnia:

≥10 mmHg increase from baseline awake PCO2 and to a value > 50 mmHg for ≥10 min; OR

PCO2 ≥55 mmHg for ≥10 min; AND

Low clinical suspicion for COPD or neuromuscular disease; AND

One of the following conditions are met:

Obesity with body mass index (BMI) ≥30 kg/m2; OR

Decreased respiratory drive due to opioid or substance use; OR

Advanced lung disease other than COPD (e.g., end-stage or advanced interstitial lung disease); AND

Individual was discharged from inpatient stay with persistent awake hypoventilation (hypercapnia) on BPAP.

A reassessment with a provider within 3 months (30 to 90 days) is required and an attended polysomnogram (PSG) should be performed to assess appropriateness of positive airway pressure modality (home sleep apnea test is acceptable if attended PSG is not obtainable); OR

Individual is ambulatory and sleep study indicates that BPAP is necessary for sleep-disordered breathing, or individual with severe obstructive sleep apnea is continuous positive airway pressure intolerant or continuous positive airway pressure was proven ineffective.

Non-invasive home mechanical ventilation may be considered medically necessary for individuals with hypoventilation syndromes who meet the following:

Qualify for a BPAP device and at least one of the following:

Higher pressure is needed to reduce hypercapnia than can be achieved with a bilevel continuous positive airway pressure device during titration (typically >25 cm H2O); OR

Severe hypoxemia requiring FIO2 >40% or >5 L/min; OR

Daytime use (battery operated unit) is required to reduce hypercapnia; OR

Tried and failed BPAP device with persistent hypercapnia despite 3 months of adequate adherence to prescribed positive airway pressure therapy with:

Awake PaCO2 ≥45 mmHg; OR

Awake venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2 ≥50 mmHg.

Triple-S considers for payment «Repetitive Nerve Stimulation (RNS)» when criteria for medically necessity exists for the diagnosis and evaluation of disorders of the neuromuscular junction.

Triple-S will consider for payment studies of evoked potentials when they are performed with the purpose of:

•           Demonstrating abnormality in the functioning of the sensory nervous system in patients with a questionable clinical presentation.

•           Help define the anatomical distribution of the disease or condition in question.

•           Objectively monitor changes over time.

•           Determine the treatment to be instituted and/or evaluate the efficacy of the same.

Indications for its use

a) Visual evoked potentials:

•           Diagnosis and monitoring of multiple sclerosis (in acute or chronic phase).

•           Location of the cause of defects in Visual fields, when it is not explained by lesions seen on CT or MRI.

•           Metabolic disorders or infectious diseases.

b) Auditory evoked potentials:

•           Evaluation of function of the brain stem in acquired metabolic disorders.

•           To assess the functional recovery after surgical removal of lesion(s) which compresses the brain stem.

•           Location of the cause of neurological deficit that is not explainable by identified lesions by CT or MRI.

•           Diagnosis and monitoring of demyelinating and degenerative diseases affecting brain stem function (multiple sclerosis, myelinolytic pontinocerebral, olivopontocerebellar degeneration, etc.)

•           Diagnosis of lesions in the auditory system.

•           Along with the EEG, for the evaluation of irreversible coma or brain death.

•           Intraoperative monitoring of brain stem auditory evoked potentials during a procedure of the spinal cord, intracranial or vascular.

•           Confirmation of the diagnosis of acoustic neuroma.

•           Determine of the type and severity of hearing problems or determine the degree of development of the nerves of the auditory system in children under five years of age.

c) Somatosensory evoked potential:

•           To validate and quantify any impairment to justify surgical intervention in patients who are unconscious, who have suffered trauma to the spinal cord and that show structural damage of the somatosensory system and those who are candidates for surgery of the spinal cord.

•           Intraoperative monitoring during surgery of the vascular, intracranial or spinal cord.

•           Diagnosis and management of specific neurological conditions that involve somatosensory system, such as multiple sclerosis and Pelizaeus-Merzbacher disease.

Triple-S shall not consider for payment studies done in the following situations:

a) Intraoperative:

1. Visual evoked potentials

2. Motor evoked potentials

b) Auditory evoked potentials for the determination of gestational age during pregnancy.

c) Somatosensory evoked potential:

1. In patients with craniocerebral trauma – not in coma, because it does not alter the management of patients.

2. In the diagnosis or management of ALS, because it is not specific for diagnosis or alters patient management.

3. In the diagnosis or management of metabolic disorders, so do not change managing these.

La topografía cerebral no se considera para pago.

Digital EEG is considered for payment:
▪ For early detection of intracranial complications during surgery neurological disorders that could result in reduced cerebral perfusion (for example: carotid endarterectomy and aneurysmal surgery).
▪ During the postoperative period; for monitoring and early detection of patients at risk of developing epileptic seizures in the care unit intensive.
▪ In the preoperative evaluation of patients with epilepsy.
▪ Extended monitoring of patients with spikes in tracings or with seizures epileptiformes, to facilitate their evaluation.
In the case that an extended digital monitoring is carried out, there is no additional payment.
Its use is not considered for payment for the following conditions:
▪ Post-concussion syndrome
▪ Mild to moderate brain trauma
▪ Learning disorders
▪ Attention disorders
▪ Schizophrenia
▪ Depression
▪ Alcoholism
▪ Abuse of controlled substances

Transmission of the EEG by telephone, radio, or cable is considered medically necessary when the closest medical facilities are located in remote areas with untrained EEG interpreters for patients with the following indications:

· Altered consciousness, such as stuporous, semi-comatose, or comatose states;

· Atypical seizure variants in patients experiencing bizarre, distressing symptoms as seen with “spike and wave stupor” or other forms of seizure disorders;

· Head injury, where a subdural hematoma may be identified; or

· Differentiation of complicated migraine with epilepsy-like symptoms (e.g., auras, alterations in level of consciousness) from true seizure disorders.

Radio and cable telemetry of the EEG is considered medically necessary with prior approval for:

· EEG recording during provocation testing (e.g., withdrawal of anticonvulsant medications), which can be safely undertaken only in the immediate proximity of emergency medical personnel and technology; and

· EEG recording attempting to localize the seizure focus prior to surgery when ambulation is desirable (e.g., when seizures are triggered by specific environmental stimuli or daily events).

Telephone transmission of the EEG to determine electrocerebral silence, i.e., brain death, is considered investigational.

Twenty-four-hour ambulatory cassette-recorded EEGs are medically necessary with prior approval in the following circumstances:

· When used in conjunction with ambulatory electrocardiogram (ECG) recordings for seizures suspected to be of cardiogenic origin;

· When used in conjunction with electrooculogram (EOG) and electromyogram (EMG) recordings for suspected seizures of sleep disturbances;

· When used for quantification of seizures in patients who experience frequent absence seizures; and

· When used in documenting seizures that are precipitated by naturally occurring cyclic events or environmental stimuli that are not reproducible in the hospital or clinical setting.

Twenty-four-hour ambulatory cassette-recorded EEGs are considered investigational in the following circumstances:

· For the study of neonates or unattended, noncooperative patients;

· In localization of seizure focus/foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization; and

· For final evaluation of patients who are being considered as candidates for resective surgery.

Video/EEG monitoring is considered medically necessary with prior approval when used to confirm the diagnosis of cases of complex seizures where treatment is defined by the seizure type. EEG video monitoring is useful for patients where a diagnosis could not be made on the basis of a neurological examination, routine EEG reporting, and ambulatory cassette EEG monitoring.

Triple-S considerará para pago el estudio electroencefalográfico en aquellas situaciones y condiciones en las que se documenta la necesidad médica.
Indicaciones principales:

Evaluación del paciente en quien se sospecha desórdenes convulsivos.

Evaluación del paciente comatoso y otras anormalidades del estado mental. El EEG es anormal en la mayoría de los casos de encefalopatía metabólica o isquémica y es normal en la mayoría de las condiciones siquiátricas.

Evaluación de procesos infecciosos del sistema nervioso central. Patrones característicos del EEG son vistos en pacientes con encefalitis por Herpes simplex, en la enfermedad de Creutzfeldt-jakob y en la panencefalitis esclerosante subaguda.

Indicaciones adicionales incluyen:

Evaluación del paciente con trauma cráneo cerebral. El EEG luego de una concusión cerebral es usualmente normal, mientras que luego de una contusión cerebral es usualmente anormal.

Evaluación de desórdenes de sueño.

Evaluación y monitoreo intraoperatorio de actividad cerebral durante procedimientos quirúrgicos tales como endarderectomía de carótidas o en cirugía cardiotoráxica.

En la evaluación de pseudoconvulsiones el EEG es normal a pesar de la presencia de actividad muscular clónica generalizada.

Electrocardiogramas asociados con electroencefalogramas
Triple-S, no considerará para pago el electrocardiograma (93000, 93005, 93010) generado previo al EEG.
De igual manera no se considerará para pago los “rhythm strips” (códigos ECG 93040, 93042), ya que los mismos se consideran como parte integral del procedimiento electroencefalográfico, no por separado.

Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.

Axillary reverse mapping/reverse lymphatic mapping performed during axillary lymph node dissection to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.

Esophageal pH monitoring using a catheter or wireless-based system may be considered medically necessary for the following clinical indications in adults and children or adolescents able to report symptoms.a

Documentation of abnormal acid exposure in endoscopy-negative individuals being considered for surgical antireflux repair;

Evaluation of individuals after antireflux surgery who are suspected of having ongoing abnormal reflux;

Evaluation of individuals with either normal or equivocal endoscopic findings and reflux symptoms refractory to proton pump inhibitor therapy;

Evaluation of refractory reflux in individuals with chest pain after cardiac evaluation and after a 1-month trial of proton pump inhibitor therapy;

Evaluation of suspected otolaryngologic manifestations of gastroesophageal reflux disease (ie, laryngitis, pharyngitis, chronic cough) in individuals who have failed to respond to at least 4 weeks of proton pump inhibitor therapy;

Evaluation of concomitant gastroesophageal reflux disease in individuals with adult-onset, nonallergic asthma suspected of having reflux-induced asthma.

Twenty-four-hour catheter-based esophageal pH monitoring may be considered medically necessary in infants or children who are unable to report or describe symptoms of reflux with:

unexplained apnea;

bradycardia;

refractory coughing or wheezing, stridor, or recurrent choking (aspiration);

persistent or recurrent laryngitis; and

recurrent pneumonia.

Twenty-four-hour catheter-based impedance pH monitoring may be considered investigational in individuals with established gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI) therapy, whose symptoms have not responded adequately to twice-daily PPI therapy, in order to define refractory GERD.

The above medically necessary indications are in accordance with the policy guidelines (see below), the 2021 American College of Gastroenterology and the 2022 American Gastroenterological Association (AGA) clinical guidelines on the clinical use of esophageal physiologic testing (see Supplemental Information).

a Esophageal pH monitoring systems should be used in accordance with U.S. Food and Drug Administration-approved indications and age ranges.

Transanal radiofrequency therapy is considered investigational as a treatment of fecal incontinence.

El análisis de pólipos colorectales por medio de fibra óptica no se considera para pago. El significado clínico de los estudios realizados es difícil de interpretar.

Percutaneous electrical nerve field stimulation for abdominal pain in individuals with irritable bowel syndrome is considered investigational.

The following specific tests for evaluating pulmonary diseases are considered for payment:

PULMONARY OBSTRUCTIVE DISEASE ESTABLISHED (EOP). This category of diseases refers to conditions that reduce the lumen of the respiratory tract and produce a quantifiable reduction of the air flow.

Tratamiento no se considera para pago, ya que no ha sido aprobado por FDA.

Se consideran para pago estos servicios en el tratamiento de las siguientes enfermedades:
Síndrome Guillain Barré

Poliomielitis

Condiciones Neuromusculares

Condiciones Restrictivas torácicas

Fallo respiratorio crónico debido a condiciones pulmonares obstructivas

Enfisema Crónico
Sarcoidosis
Fallo respiratorio debido a condiciones neurológicas

Los servicios de asistencia y manejo del ventilador ofrecido por el neumólogo a pacientes hospitalizados se consideran para pago al ser facturados individualmente.
Los servicios de asistencia y manejo del ventilador se consideran para pago como tratamiento en el hogar.
No se consideran para pago los códigos de asistencia y manejo del ventilador, al ser facturados junto con códigos de visita o consulta en hospital.

Oximetry is considered for payment when:

It is performed at the physician’s office or at the patient’s home for the following conditions:

–    Failure to Thrive
–    Cardiac Congestive Failure
–    Lung Fibroquistic Disease
–    Asthmatic state
–    Bronchiectasia
–    Alveolitis
–    Chronic Obstructive Asthma
–    Patients using oxygen at home

Oximetry is not considered for payment when:

1.    It is performed at an ambulatory surgery facility or in a hospital because they are included in their per diem.

2.    It is used under supervision for intravenous sedation at the office.

3.    Used with surgical procedures classified as Type 2 and is performed in the office, for it is considered a necessary element or factor to perform the procedure.

The values obtained must be documented in the clinical file. Other obstructive condition will be evaluated on its merit for payment.

Transcatheter arterial chemoembolization of the liver may be considered medically necessary:

to treat hepatocellular cancer that is unresectable but confined to the liver and not associated with portal vein thrombosis and liver function not characterized as Child-Pugh class C

as a bridge to transplant in patients with hepatocellular cancer where the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant (see Policy Guidelines section)

to treat liver metastasis in symptomatic patients with metastatic neuroendocrine tumor whose symptoms persist despite systemic therapy and who are not candidates for surgical resection

to treat liver metastasis in patients with liver-dominant metastatic uveal melanoma.

Transcatheter arterial chemoembolization of the liver is considered investigational:

as neoadjuvant or adjuvant therapy in hepatocellular cancer that is considered resectable

as part of combination therapy (with radiofrequency ablation) for resectable or unresectable hepatocellular carcinoma

to treat unresectable cholangiocarcinoma

to treat liver metastases from any other tumors or to treat hepatocellular cancer that does not meet the criteria noted above, including recurrent hepatocellular carcinoma

to treat hepatocellular tumors prior to liver transplantation except as noted above.

El trasplante hematopoyético de células madre Individual o en tándem no se considera para pago para tratar cualquier etapa del cáncer de mama.
El trasplante hematopoyético alogénico de células madres no se considera para pago para el tratamiento de cualquiera de las etapas del cáncer de mama.

Allogeneic hematopoietic cell transplantation is considered medically necessary for select patients with the following disorders.

Hemoglobinopathies

Sickle cell anemia for children or young adults with either a history of prior stroke or at increased risk of stroke or end-organ damage.

Homozygous b-thalassemia (ie, thalassemia major).

Bone Marrow Failure Syndromes

Aplastic anemia including hereditary (including Fanconi anemia, dyskeratosis congenita, Shwachman-Diamond syndrome, Diamond-Blackfan syndrome) or acquired (eg, secondary to drug or toxin exposure) forms.

Primary Immunodeficiencies

Absent or defective T-cell function (eg, severe combined immunodeficiency, Wiskott-Aldrich syndrome, X-linked lymphoproliferative syndrome) or

Absent or defective natural killer function (eg, Chédiak-Higashi syndrome) or

Absent or defective neutrophil function (eg, Kostmann syndrome, chronic granulomatous disease, leukocyte adhesion defect).

(See Guideline 1.)

Inherited Metabolic Diseases

Lysosomal and peroxisomal storage disorders except for Hunter, Sanfilippo, and Morquio syndromes.

(See Guideline 2.)

Genetic Disorders Affecting Skeletal Tissue

Infantile malignant osteopetrosis (Albers-Schonberg disease or marble bone disease).

El rastreo intrafraccionario en tiempo real para ajustar dosis o para el monitoreo del movimiento de la tarjeta durante radioterapia no procede para pago.
Técnicas de “gaiting” respiratorio para la entrega de radioterapia no se considera para pago.

Donantes de infusión de linfocitos procede para pago después de trasplante-alogeneico hematopoyético de células (HCT) que fue considerado originalmente médicamente necesario para el tratamiento de una neoplasia hematológica que han sufrido una recaída o refractaria, para prevenir la recaída en el establecimiento de un alto riesgo de recaída o para convertir a un paciente entre un donante de quimerismo variado o completo.

La infusión de linfocitos de donantes no procede para pago seguido por TCMH alogénico para el tratamiento de una neoplasia hematológica.

La infusión de linfocitos de donantes no procede para pago como tratamiento de neoplasias no hematológicas tras un TPH alogénico anterior.

La modificación genética de los linfocitos del donante no procede para pago.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of surgery may be considered medically necessary for the treatment of:

pseudomyxoma peritonei; and

diffuse malignant peritoneal mesothelioma.

The use of HIPEC may be considered medically necessary in newly diagnosed epithelial ovarian or fallopian tube cancer at the time of interval cytoreductive surgery when ALL of the following criteria are met:

The individual has stage III disease (see Policy Guidelines);

The individual is not eligible for primary cytoreductive surgery or surgery had been performed but was incomplete and will receive neoadjuvant chemotherapy and subsequent interval debulking surgery (see Policy Guidelines); and

It is expected that complete or optimal cytoreduction can be achieved at time of the interval debulking surgery (see Policy Guidelines).

The use of HIPEC in all other settings to treat ovarian cancer, including but not limited to stage IIIC or IV ovarian cancer, is considered investigational.

Cytoreductive surgery plus HIPEC is considered investigational for:

peritoneal carcinomatosis from colorectal cancer, gastric cancer, or endometrial cancer; and

all other indications, including goblet cell tumors of the appendix.

Transcatheter mitral valve repair (TMVR) with a device approved by the U.S. Food and Drug Administration (FDA) for use in mitral valve repair may be considered medically necessary for individuals with symptomatic, primary mitral regurgitation (MR) who are considered at prohibitive risk for open surgery (see Policy Guidelines section).

TMVR with a device approved by the U.S. FDA may be considered medically necessary for individuals with heart failure and moderate-to-severe or severe symptomatic secondary MR despite the use of maximally tolerated guideline-directed medical therapy (see Policy Guidelines section).

TMVR is considered investigational in all other situations.

The use of ultrafiltration is considered investigational in patients with heart failure.

The use of a device with U.S. Food and Drug Administration (FDA) approval for percutaneous left atrial appendage closure (e.g., the Watchman or Amplatzer Amulet) may be considered medically necessary for the prevention of stroke in individuals with atrial fibrillation when the following criteria are met:

There is an increased risk of stroke and systemic embolism based on CHADS2 or CHA2DS2-VASc score and systemic anticoagulation therapy is recommended; and

The long-term risks of systemic anticoagulation outweigh the risks of the device implantation (see Policy Guidelines).

The use of a device with FDA approval for percutaneous left atrial appendage closure (e.g., the Watchman or Amplatzer Amulet) for stroke prevention in individuals who do not meet the above criteria is considered investigational.

The use of other percutaneous left atrial appendage closure devices, including but not limited to the Lariat and Amplatzer Cardiac Plug devices, for stroke prevention in individuals with atrial fibrillation is considered investigational.

Myocardial strain imaging in individuals who have exposure to medications or radiation that could result in cardiotoxicity is investigational.

Myocardial strain imaging is investigational in all other situations.

The use of phrenic nerve stimulation for central sleep apnea is considered investigational in all situations.

The Micra™ VR or Aveir™ (see Policy Guidelines) single-chamber transcatheter pacing system may be considered medically necessary in individuals when both conditions below are met:

The individual has high-grade atrioventricular (AV) block (see Policy Guidelines) in the presence of atrial fibrillation or has significant bradycardia and:

Normal sinus rhythm with rare episodes of 2° or 3° AV block or sinus arrest (see Policy Guidelines); OR

Chronic atrial fibrillation; OR

Severe physical disability (see Policy Guidelines).

The individual has a significant contraindication precluding placement of conventional single-chamber ventricular pacemaker leads such as any of the following:

History of an endovascular or cardiovascular implantable electronic device (CIED) infection or who are at high risk for infection (see Policy Guidelines);

Limited access for transvenous pacing given venous anomaly, occlusion of axillary veins or planned use of such veins for a semi-permanent catheter or current or planned use of an arteriovenous fistula for hemodialysis;

Presence of a bioprosthetic tricuspid valve.

The Micra™ AV single-chamber transcatheter pacing system may be considered medically necessary in individuals when both conditions below are met:

The individual has high-grade AV block (see Policy Guidelines) in the presence of atrial fibrillation or has significant bradycardia and:

Normal sinus rhythm with rare episodes of 2° or 3° AV block or sinus arrest (see Policy Guidelines); OR

Chronic atrial fibrillation; OR

Severe physical disability (see Policy Guidelines); OR

There is an indication for VDD pacing and the individual may benefit from maintenance of AV synchronous ventricular pacing (see Policy Guidelines).

The individual has a significant contraindication precluding placement of conventional single-chamber ventricular pacemaker leads such as any of the following:

History of an endovascular or cardiovascular implantable electronic device (CIED) infection or who are at high risk for infection (see Policy Guidelines);

Limited access for transvenous pacing given venous anomaly, occlusion of axillary veins or planned use of such veins for a semi-permanent catheter or current or planned use of an arteriovenous fistula for hemodialysis;

Presence of a bioprosthetic tricuspid valve.

The Micra™ and Aveir™ single-chamber transcatheter pacing systems are considered investigational in all other situations in which the above criteria are not met.

Se considera para pago la Galleta de carmustine, única y exclusivamente en los casos de glioblastoma multiforme y astrocitoma anaplástico.

The percutaneous transcatheter closure of a patent foramen ovale using a device that has been approved by the U.S. Food and Drug Administration for that purpose  may be considered medically necessary to reduce the risk of recurrent ischemic stroke if patient meets all of the following:

Between 18 and 60 years of age
Diagnosed with patent foramen ovale with a right-to-left interatrial shunt confirmed by echocardiography with at least one of the following characteristics:

PFO with large shunt, defined as >30 microbubbles in the left atrium within 3 cardiac cycles, after opacification of the right atrium.
PFO associated with atrial septal aneurysm on transesophageal examination: septum primum excursion >10 mm

Documented history of cryptogenic ischemic stroke due to a presumed paradoxical embolism, as determined by a neurologist and cardiologist following an evaluation to exclude any other identifiable cause of stroke, including large vessel atherosclerotic disease and small vessel occlusive disease

AND none of the following are present:

Uncontrolled vascular risk factors, including uncontrolled diabetes or uncontrolled hypertension
Other sources of right-to-left shunts, including an atrial septal defect and/or fenestrated septum.
Active endocarditis or other untreated infections
Inferior vena cava filter.

Transcatheter closure of secundum atrial septal defects may be considered medically necessary when using a device that has been approved by the U.S. Food and Drug Administration for that purpose and used according to the labeled indications including:

Patients with echocardiographic evidence of ostium secundum atrial septal defect;

AND either of the following

Clinical evidence of right ventricular volume overload (ie, 1.5:1 degree of left-to-right shunt or right ventricular enlargement); OR
Clinical evidence of paradoxical embolism.

Transcatheter closure of secundum atrial septal defects is considered investigational for all other indications not meeting criteria outlined above.

In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart failure using implantable direct pressure monitoring of the pulmonary artery, thoracic bioimpedance, inert gas rebreathing, and arterial pressure during the Valsalva maneuver is considered investigational

Percutaneous transluminal septal myocardial ablation may be considered medically necessary as a treatment of hypertrophic obstructive cardiomyopathy.

Progenitor cell therapy, including but not limited to skeletal myoblasts or hematopoietic cells, is considered investigational as a treatment of damaged myocardium.

Infusion of growth factors (ie, granulocyte colony stimulating factor) is considered investigational as a technique to increase the numbers of circulating hematopoietic cells as treatment of damaged myocardium.

Transcatheter radiofrequency ablation (RFA) or cryoablation to treat atrial fibrillation may be considered medically necessary as a treatment for either of the following indications, which have failed to respond to adequate trials of antiarrhythmic medications:

Symptomatic paroxysmal or symptomatic persistent atrial fibrillation; or

As an alternative to atrioventricular nodal ablation and pacemaker insertion in individuals with class II or III congestive heart failure and symptomatic atrial fibrillation.
Transcatheter RFA or cryoablation to treat atrial fibrillation may be considered medically necessary as an initial treatment for individuals with recurrent symptomatic paroxysmal atrial fibrillation (>1 episode, with ≤4 episodes in the previous 6 months) in whom a rhythm-control strategy is desired.

Repeat RFA or cryoablation may be considered medically necessary in individuals with recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure (see Policy Guidelines section).

Transcatheter RFA or cryoablation to treat atrial fibrillation is considered investigational as a treatment for cases of atrial fibrillation that do not meet the criteria outlined above.

Correlated audioelectric cardiography is considered investigational.

La subclasificación de lipoproteínas de alta densidad en el cernimiento, diagnóstico y manejo de enfermedad cardiovascular no se considera para pago. Estudios retrospectivos sugieren que el efecto protector está principalmente asociado a la subclase HDL-2, sin embargo estos estudios no pueden determinar si la disminución de HDL-2 precede el desarrollo de la enfermedad cardiovascular o fue resultado de ésta.

The use of patient-activated or auto-activated external ambulatory event monitors (AEMs) OR continuous ambulatory monitors that record and store information for periods longer than 48 hours may be considered medically necessary as a diagnostic alternative to Holter monitoring in the following situations:

Individuals who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (ie, palpitations, dizziness, presyncope, or syncope).

Individuals with atrial fibrillation (AF) who have been treated with catheter ablation, and in whom discontinuation of systemic anticoagulation is being considered.

Individuals with cryptogenic stroke who have a negative standard workup for AF including a 24-hour Holter monitor (see Policy Guidelines section).

The use of implantable AEMs, either patient-activated or auto-activated, may be considered medically necessary in the following situations:

In the small subset of individuals who experience recurrent symptoms so infrequently that a prior trial of other external AEMs has been unsuccessful.

In individuals who require long-term monitoring for AF or possible AF (see Policy Guidelines section).

The use of outpatient cardiac telemetry (also known as mobile cardiac outpatient telemetry) as a diagnostic alternative to AEMs in individuals who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, syncope) is considered investigational.

Other uses of AEMs, including outpatient cardiac telemetry and mobile applications, are considered investigational, including but not limited to monitoring asymptomatic individuals with risk factors for arrhythmia, monitoring the effectiveness of antiarrhythmic medications, and detection of myocardial ischemia by detecting ST-segment changes.

Use of wearable cardioverter defibrillators (WCDs) for the prevention of sudden cardiac death is considered medically necessary as interim treatment for those who:

meet the criteria for an implantable cardioverter defibrillator (ICD; see indications in evidence review 07.001.050); and

have a temporary contraindication to receiving an ICD, such as as the ICD waiting period or a systemic infection, at the current time; and

have been scheduled for an ICD placement or who had an ICD removed and have been rescheduled for placement of another ICD once the contraindication is treated; and

patients with a permanent implantable cardioverter-defibrillator (ICD) that must be explanted, or those with a delay in implanting a newly indicated ICD (eg, due to systemic infection).

patients with reduced left ventricular (LV) systolic function (LVEF ≤35 percent) who have had a myocardial infarction (MI) within the past 40 days.

patients with reduced LV systolic function (LVEF ≤35 percent) who have undergone coronary revascularization with coronary artery bypass graft (CABG) surgery in the past three months.

patients with newly diagnosed nonischemic cardiomyopathy with severely reduced LV systolic function (LVEF ≤35 percent) that is potentially reversible.

patients with severe heart failure who are awaiting heart transplantation at high risk for lethal arrhythmias.

women with peripartum cardiomyopathy with reduced LV systolic function (LVEF ≤35 percent)

patient with familial or inherited conditions with a high risk of life threatening ventricular tachyarrhythmia such as long QT syndrome or hypertrophic cardiomyopathy

Use of WCDs for the prevention of sudden cardiac death is considered investigational for the following indications when they are the sole indication for a WCD:

Patients in the immediate (ie, <40 days) period following an acute myocardial infarction Patients post coronary artery bypass graft surgery High-risk patients awaiting heart transplant Patients with newly diagnosed nonischemic cardiomyopathy Women with peripartum cardiomyopathy. Use of WCDs is considered investigational for all other indications.

Cardiografía acústica no procede para pago en el diagnóstico de la insuficiencia cardíaca y para la optimización de los parámetros hemodinámicos en terapia de resincronización cardiaca (CRT).

Optical coherence tomography is considered investigational when used as an adjunct to percutaneous coronary interventions with stenting.

Optical coherence tomography is considered investigational in all other situations, including but not limited to, risk stratification of intracoronary atherosclerotic plaques and follow-up evaluation of stenting.

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
obesity

Computerized 2-lead resting electrocardiogram analysis (eg, multifunction cardiogram) is considered investigational for diagnosing coronary artery disease.

La electrocardiografía de derivación sencilla no se considera para pago. Su uso como una técnica de estratificación de riesgo para arritmias posterior a un infarto al miocardio incluye pero no se limita a:
Pacientes con Cardiomiopatía

Pacientes con síncope

Como una evaluación de éxito después de cirugía para arritmia

En la detección de rechazo agudo en trasplante cardiaco

Como evaluación de eficacia en terapias con drogas antiarrítmicas.

En la evaluación de resultados farmacológicos, mecánicos e intervenciones quirúrgicas para restaurar el flujo de sangre coronario.

Esta política obedece a que no hay datos que directamente relacionen la estratificación de riesgo en estos casos por electrocardiografía de derivación sencilla, que mejore los resultados, mejore la eficiencia o reduzca costos en estos pacientes.

1.  EKG services are covered diagnostic tests when there are documented signs and symptoms or other clinical indications for providing the service. EKG services should not routinely be performed as part of a preventive exam unless the member has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test.

2. Billing separately from the interpretation of ECG made and ordered as part of a visit or consultation is considered for payment.

3. The insured is not responsible for payment, when the EKG is denied for not being medically reasonable.

4. Code 93041 (Rhythm plotting; no interpretation, no report) is considered for payment only to authorized suppliers.

5. The production of the plot, if done in the office of a doctor and another provider (also a participant) interprets it, will be paid to the first, the production (93005) and to the second the interpretation (93010).

6. If the code 93041 is produced in the hospital, it is not considered for payment, since the production of the code 93041 is a covered service in the hospital contract.

7. Electrocardiographic monitoring is considered for payment at:

a) Arrhythmias; or at the beginning of any treatment therapy for arrhythmias.

b) As a treatment to monitor:

1) pulse irregularities

2) chest pain

3) palpitations

4) tachyarrhythmias

5) bradyarrhythmias

6) syncope

Electrocardiograms associated with the Stress Test and the Holter

Billing codes 93000-93010 (electrocardiogram) are included in the payment of the Holter (93224) and in the stress test (Stress Test 93015). If you have performed an electrocardiogram within a period of six weeks prior to the Holter or Stress Test, payment of the electrocardiogram will be denied when invoiced with these services.

Electrocardiograms associated with echocardiograms

Triple-S does not consider “rhythm strips” (ECG code 93040, 93042) for payment, since they are considered an integral part of monitoring during the echocardiographic procedure. If EKG 12 “lead” is made and documented separately from 93307, it proceeds for payment.

Implantable ventricular assist devices (VADs) with U.S. Food and Drug Administration (FDA) approval or clearance may be considered medically necessary as destination therapy for adult individuals with end-stage heart failure who meet the following criteria:

New York Heart Association (NYHA) Class III heart failure with dyspnea upon mild physical activity or NYHA Class IV;

Left ventricular ejection fraction ≤25%;

Inotrope-dependent; OR cardiac index <2.2 liters/min/m2, while not on inotropes and also meeting one of the following: On optimal medical management, based on current heart failure practice guidelines for at least 45 of the last 60 days and are failing to respond, OR Advanced heart failure for at least 14 days and dependent on intra-aortic balloon pump for ≥7 days. Bridge to Transplantation Implantable VADs with FDA approval or clearance may be considered medically necessary as a bridge to heart transplantation for individuals who are: Currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, OR Are undergoing evaluation to determine candidacy for heart transplantation. Implantable VADs with FDA approval or clearance, including humanitarian device exemptions, may be considered medically necessary as a bridge to heart transplantation in children 16 years old or younger who are: Currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, OR Are undergoing evaluation to determine candidacy for heart transplantation. Total artificial hearts (TAHs) with FDA approved devices may be considered medically necessaryas a bridge to heart transplantation for individuals with biventricular failure who: Have no other reasonable medical or surgical treatment options, are ineligible for other univentricular or biventricular support devices, and are currently listed as heart transplantation candidates, OR Have no other reasonable medical or surgical treatment options, are ineligible for other univentricular or biventricular support devices, are undergoing evaluation to determine candidacy for heart transplantation, and not expected to survive until a donor heart can be obtained. Postcardiotomy Setting/Bridge to Recovery Implantable VADs with FDA approval or clearance may be considered medically necessary in the postcardiotomy setting in individuals who are unable to be weaned off cardiopulmonary bypass. Other Indications Other applications of implantable ventricular assist devices (VADs) or total artificial hearts (TAHs) are considered investigational, including, but not limited to, the use of TAHs as destination therapy. The use of non-FDA-approved or cleared implantable VADs or TAHs is considered investigational. Percutaneous VADs are considered investigational for all indications.

Braquiterapia intravascular coronaria usando radiación beta o gamma se considera para pago como tratamiento de la reestenosis del “stent” metálico en una arteria coronaria nativa.
Braquiterapia intravascular usando radiación beta o gamma se considera para pago como tratamiento de la reestenosis del “stent” en una arteria coronaria no-nativa (i.e. injerto de la vena safena).
Braquiterapia intravascular coronaria como tratamiento para reducir el riesgo de una re estenosis con un stent medicado con sirolimus o no medicado no se considera para pago, ya que su uso en esta indicación ha ido disminuyendo.
Braquiterapia intravascular en el sistema femoropoplíteo no se considera para pago, ya que no hay dispositivos específicos para su uso en el sistema periferal arterial.
Braquiterapia intravascular coronaria no se considera para pago como tratamiento para prevenir reestenosis de novo, en conjunto con PTCA con o sin uso de stent.

Esta tecnología no invasiva se considera para pago, en adultos y niños para medir gasto cardiaco, velocidad de flujo, presiones intracardiacas y sus variaciones, diagnóstico y evaluación de severidad de daño valvular y otras anormalidades estructurales ( Ej. Defectos septales).
Debe ser usado para orientar la dirección del tratamiento y no como un procedimiento rutinario. La información obtenida a través de este método es usualmente complementaria.
Las anomalías significativas usualmente requieren evaluación invasiva, tales como cateterismo cardíaco, angiografía, etc. Es por esta razón que usualmente no es necesario repetir estos estudios a corto plazo.
Los asegurados que se les realice el “ecocardiography, transthoracic with spectral doppler ecocardiography and color flow doppler” y no tienen el beneficio en su cubierta de el color flow, Triple S Salud reconoce para pago el 93306. La tarifa de este código incluye el 2b, M mode y doppler spectral. El pago de la porción de color flow es responsabilidad del asegurado.

Si el cardiólogo sólo supervisa una prueba de esfuerzo cardiovascular, debe usar el código 93016.

Si el cardiólogo sólo hace interpretación e informe utilizará código 93018.

Si el cardiólogo sólo realiza el trazado, utilizará el código 93017. De igual forma, si el equipo utilizado pertenece a una instalación, se usará el código 93017.

Para facturar el procedimiento completo, incluso la interpretación de imágenes trazadas y si es dueño del equipo, usará el código 93015. De ser necesario utilizará el código radiológico (78453 ó 78454).

Este es un servicio global.

Los Cardiólogos Nucleólogos pueden reportar pruebas de esfuerzo cardiovascular con el código de medicina nuclear (78453, 78454, 78481 y 78483).

Si un cardiólogo y un radiólogo hacen el procedimiento en conjunto, el radiólogo debe usar los códigos de Medicina Nuclear.

Triple-S considers for payment an EKG (code 93000) prior to a ambulatory procedure and under intravenous sedation, only in high-risk patient’s risk, example:

A. Severe cardiovascular problems:

1) angina pectoris

2) history of arrhythmias

3) cardiac dysfunction

4) myocarditis

5) patients with permanent pacemakers or implanted defibrillators

B. Conditions Associated With, or Increased Risk of Disease cardiovascular:

1) advanced age > 45 years of age

2) diabetes

3) hyperlipidemia

4) smoking

5) lung diseases

6) peripheral vascular diseases

7) hypo and/or hyperthyroidism

8) collagen diseases

9) muscular dystrophies

10) liver or kidney failure

11) electrolyte disorders

12) morbid obesity (double or increase of 100lbs. of the ideal weight)

C. Use of drugs that carry the potential for cardiac toxicity:

1) antineoplastic drugs

a) doxorubicin

b) Epirubicin

c) Daunorubicin

d) Idarubicin

e) Pyrubicin

2) lithium

3) phenothiazides

4) tricyclic antidepressants

5) erythromycin

D. Neurological disorders

1. Autonomic Neuropathies

2. Documentation:

The justification for performing the EKG must be duly documented in the patient file. If it is not included, it will be considered as absence of medical necessity and payment will not be considered.

Ultrasonographic measurement of carotid intima-media thickness as a technique for identifying subclinical atherosclerosis is considered investigational for use in the screening, diagnosis, or management of atherosclerotic disease.

Biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator) may be considered medically necessary as a treatment of heart failure in patients who meet all of the following criteria:

For New York Heart Association class III or IV,

Left ventricular ejection fraction ≤35%
Sinus rhythm
Patients treated with guideline-directed medical therapy (see Policy Guidelines section)

AND

Either left bundle branch block OR QRS interval ≥150 ms.

For New York Heart Association class II,

Left ventricular ejection fraction ≤30%
Sinus rhythm
Patients treated with a guideline-directed medical therapy (see Policy Guidelines section)

AND

Either left bundle branch block OR QRS interval ≥150 ms.

For patients who do not meet the criteria outlined above, but have an indication for a ventricular pacemaker or biventricular pacemakers with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker/implantable cardiac defibrillator) may be considered medically necessary asan alternative to a right ventricular pacemaker in patients who meet all of the following criteria:

New York Heart Association class I, II, III, or IV heart failure;
Left ventricular ejection fraction ≤50%;
The presence of atrioventricular block with requirement for a high percentage of ventricular pacing (see Policy Guidelines section); and
Patients treated with guideline-directed medical therapy (see Policy Guidelines section).

Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator), are considered investigational as a treatment for patients with New York Heart Association class I heart failure who do not meet the above criteria.

Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (ie, a combined biventricular pacemaker plus implantable cardiac defibrillator), are considered investigational as a treatment for heart failure in patients with atrial fibrillation who do not meet the above criteria.

Triple-site (triventricular) cardiac resynchronization therapy, using an additional pacing lead, is considered investigational.

An intrathoracic fluid monitoring sensor is considered investigational as a component of a biventricular pacemaker.

Cardiac resynchronization therapy with wireless left ventricular endocardial pacing is considered investigational.

Catheter ablation may be considered medically necessary for the treatment of supraventricular tachyarrhythmias, as follows:

Treatment of paroxysmal supraventricular tachycardia due to AV nodal re-entry tachycardia
Treatment of paroxysmal supraventricular tachycardia due to accessory pathways
Treatment of atrial flutter
Treatment of focal atrial tachycardia

Catheter ablation using radiofrequency energy may be considered medically necessary for the treatment of chronic, recurrent, ventricular tachycardia that is refractory to implantable cardioverter-defibrillator treatment and antiarrhythmic medications, and for which an identifiable arrhythmogenic focus can be identified.

Catheter ablation for ventricular tachycardia “storm” (see Policy Guidelines), may be considered medically necessary when pharmacologic treatment has been unsuccessful in controlling the arrhythmia.

Catheter ablation for all other ventricular arrhythmias is considered investigational.

Enhanced external counterpulsation is considered investigational for all indications, including but not limited to, treatment of chronic stable angina pectoris, heart failure, erectile dysfunction, or ischemic stroke.

Automated ambulatory blood pressure (BP) monitoring over a 24-hour period may be considered medically necessary for individuals with elevated office BP when performed 1 time to differentiate between «white coat hypertension» and true hypertension, and when the following conditions are met (see Policy Guidelines section for considerations in pediatric patients):

Office BP elevation is in the mild-to-moderate range (<180/110 mm Hg), not requiring immediate treatment with medications; and There is an absence of hypertensive end-organ damage on physical examination and laboratory testing. All other uses of ambulatory BP monitoring for individuals with elevated office BP are considered investigational, including but not limited to repeated testing in individuals with persistently elevated office BP and monitoring of treatment effectiveness.

End-diastolic pneumatic compression boots are considered investigational as a treatment of peripheral vascular disease or lymphedema and its associated complications, including but not limited to ischemic lesions, claudication pain, necrotizing cellulitis, venous stasis ulcers, stasis dermatitis, chronic lymphedema, or thrombophlebitis.

Vestibular function testing using an electronystagmography and videonystagmography testing batteries, caloric testing, or rotational chair testing may be considered medically necessary when the following conditions have been met:

The patient has symptoms of a vestibular disorder (eg, dizziness, vertigo, imbalance); and

A clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has failed to identify the cause of the symptoms.

Vestibular evoked myogenic potential tests are considered investigational.

Vestibular function testing for the assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically is not medically necessary.

Repeat vestibular function testing when treatment resolves symptoms is not medically necessary.

Vestibular function testing in all other situations is investigational.

All other laboratory-based vestibular function tests not described above are considered investigational.

Biofeedback for constipation in adults may be considered medically necessary for patients with dyssynergia-type constipation as demonstrated by meeting all 3 of the following criteria:

Symptoms of functional constipation that meet Rome IV criteria (see Policy Guidelines section).

Objective physiologic evidence of pelvic floor dyssynergia (see Policy Guidelines section) demonstrated by inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or electromyography;

Failed a 3-month trial of standard treatments for constipation including laxatives, dietary changes, and exercises (as many of the previous as are tolerated).

Biofeedback is considered investigational as a treatment of constipation in adults and children in all other situations.

Biofeedback is considered investigational as a treatment of fecal incontinence in adults and children.

Neural therapy is considered investigational for all indications.

Use of confocal laser endomicroscopy is considered investigational.

Peroral endoscopic myotomy is considered investigational as a treatment for pediatric and adult esophageal achalasia.

Gastric peroral endoscopic myotomy is considered investigational as a treatment for gastroparesis.