About this policy
Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD
Coverage indications
Overview This is a coverage policy for contrast (also known as ultrasound enhancing agent-UEA) administration for purposes of echocardiographic myocardial perfusion evaluation. Decades of work have been invested in the refinement of microbubble technology for UEAs. Much focus has also been brought to bear on optimization of echocardiographic settings, software and hardware to facilitate this technology. Huge advances have been made over these many years. Commercially available UEAs that are approved for use by the United States Food and Drug Administration are composed of encapsulated microbubbles. The use of these microbubbles is based on their ability to undergo volumetric oscillation in the pressure fluctuations of the ultrasound field. Microbubble vibration can occur without compromise of its integrity (stable cavitation) or can be accompanied by either sudden or gradual destruction from exaggerated non-linear oscillation when ultrasound is delivered at high ultrasound pressure amplitude. This process allows for a strong acoustic signature that can be separated from tissue with specially designed and commercially available imaging protocols. There are currently 3 UEAs approved by the FDA. The only FDA-approved use in cardiovascular disease is for left ventricular opacification (LVO) using IV injections. LVO is used to better define endocardial borders when accurate dimensions and volumes cannot be readily obtained because of the poor quality of endocardial visualization. Suboptimal images limit unenhanced echocardiographic interpretation in a substantial percentage of studies. Many off-label uses for UEAs exist and have been investigated for years. These uses include, but are not limited to, applications related to myocardial perfusion and viability. This LCD addresses the issue of coverage for some of these off-label uses. Noncovered Services Use of non-FDA approved UEAs The administration of UEAs for myocardial perfusion evaluation strictly for screening purposes
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.