Transesophageal Echocardiogram…

About this policy

Jurisdiction: J9 MAC Part B. States: Florida, Puerto Rico, US Virgin Islands. Type: Active LCD

Coverage indications

History/Background and/or General Information Transesophageal Echocardiography (TEE) is a cardiac diagnostic procedure in which a modified endoscope, with an ultrasound transducer, is passed into the esophagus and/or stomach in order to obtain 2-D/3D echo images and spectral and color Doppler information about the heart and its great vessels. Transesophageal Echocardiography (TEE) imaging is a viable alternative when transthoracic imaging is problematic or difficult. In many instances, abnormalities can be displayed that are missed with standard diagnostic techniques, and the images displayed are often of superior quality because of the high-resolution probes that can be used. Covered Indications 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 Limitations As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual , Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Codes in this policy

Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
93312	CPT	Covered
93313	CPT	Covered
93314	CPT	Covered
93315	CPT	Covered
93316	CPT	Covered
93317	CPT	Covered
93318	CPT	Covered
93355	CPT	Covered
C8925	HCPCS	Covered
C8926	HCPCS	Covered
C8927	HCPCS	Covered
A18.84	ICD10CM	Covered
B95.61

Coverage indications

Codes in this policy

Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
93312	CPT	Covered
93313	CPT	Covered
93314	CPT	Covered
93315	CPT	Covered
93316	CPT	Covered
93317	CPT	Covered
93318	CPT	Covered
93355	CPT	Covered
C8925	HCPCS	Covered
C8926	HCPCS	Covered
C8927	HCPCS	Covered
A18.84	ICD10CM	Covered
B95.61

About this policy

Coverage indications

Codes in this policy

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Coverage indications

Codes in this policy

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