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Medical Policy: 02.02.06
Original Effective Date: August 2001
Reviewed: May 2012
Revised: August 2003
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Microvolt T-wave alternans testing, also known as T-wave alternans(TWA) is a noninvasive technique used to identify patients who are at high or low risk for sudden cardiac death or cardiac arrest due to ventricular tachyarrhythmias. T-wave alternans refers to a beat-to-beat variability in the amplitude of the T- wave portion of the electrocardiogram (ECG) tracing. It is measured by a provocative test that requires gradual elevation of the heart rate to more than 110 beats per minute. Test results are reported as the number of standard deviations (SDs) by which the peak signal of the T-wave exceeds the background noise. The number is referred to as the alternans ration. An alternans ratio of 3 or greater is typically considered a positive result; an absent alternans ration is considered a negative result, and other values are indeterminate.
The presence of T-wave alternans has been investigated as a risk stratification tool to predict the likelihood of fatal arrhythmias and sudden cardiac death in patients with a history of myocardial infarction or cardiomyopathy. Research has shown that a negative T-wave alternans test result means there is very minimal risk of the patient developing ventricular tachyarrhythmias and can therefore help shape the treatment plan by sparing the risk and expense of surgery for treatment with an implantable cardioverter defibrillator (ICD), or pacemaker. Conversely, a positive test result will allow the treatment team to explore more aggressive means of managing the patient, such as medication or treatment with an ICD.
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Prior Approval:
Not applicable
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Policy:
T-wave alternans testing may be considered medically necessary for patients who meet one or more of the following criteria:
- Presence of unexplained syncope or pre-syncopal episodes with known or suspected heart disease, or abnormal ECG, or occurring suddenly or with exertion, or with risk factors for coronary artery disease
- History of syncope, pre-syncope or complex ectopy where there is a suspicion of congenital cardiac disorder or family history of sudden death
- Sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) associated with a transient or reversible cause such as ischemia, cardiac surgery, drug overdose, etc.
- Suspected or documented non-sustained ventricular tachycardia and left ventricular dysfunction or
- Symptomatic cardiac arrhythmias of undetermined origin.
Note: T-wave alternans testing cannot be performed accurately unless the patient is in sinus rhythm and the ventricular rate is greater than 105 beats per minute. It should also not be performed on patients in atrial fibrillation or on patients who cannot sustain a provoked ventricular rate of at least 105 beats per minute for a least one full minute. T-wave alternans testing should be performed at least 3-4 weeks after myocardial infarction to ensure accurate results as the presence of the alternans fluctuates during the period following an MI due to healing of the myocardium.
TWA is considered investigational for use as a general assessment of patients with atherosclerotic heart disease, congestive heart failure, pre-surgical evaluation or other circumstances with low suspicion of VT or VF, or when the knowledge of possible VT/VF is not expected to alter the treatment plan.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 93025 T-wave alternans testing.
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Selected References:
- Klingenheben T, Siedow A, Credner SC, Gronefeld G, Zebel M, Li YG, Hohnloser SH. T-Wave alternans in microwave frequency as a new indicator of disordered ventricular repolarization: Pathophysiology, methodology, and clinical results. Zeitschrift Fur Kardiologie 1999 Dec; 88(12):974-981.
- Klingenheben T, Credner S, Li YG, Bender B, Hohnloser SH. Microvolt level T-Wave Alternans: a new marker for noninvasive risk stratification. Zeitschrift Fur Kardiologie Supplementum 2000; 89 suppl3:57-61
- Gold MR, Bloomfield DM, Anderson KP, El-Sherif NE, Wilber DJ, Groh WJ, Estes NA, Kaufman ES, Greenberg ML, Rosenbaum, D.S. A comparison of T-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification. Journal of the American College of Cardiology 2000 Dec; 37 (7): 2247-53 and 2254-2256.
- Hunt AC. T Wave Alternans in high arrhythmic risk patients: Analysis in time and frequency domain: a pilot study. Biomed Central Cardiovascular Disorders; 2002-Mar 12;2(1):6.
- Osman AF, Gold MR. T wave alternans for ventricular arrhythmia risk stratification. Current Opinions in Cardiology; 2002 - Jan; 18(1):1-5.
- Klingenheben T. Hohnloser SH. Clinical value of T-wave alternans assessment. Cardiac Electophysiology Review 2002: 6:323-328.
- Chow T, Kereiakes DJ, Bartone C et al. Prognostic utility of microvolt T-wave alternans in risk stratification of patients with ischemis cardiomyopathy. J Am Coll Cardiol 2006; 47:1820-1827.
- Salerno-Uriarte JA, De Ferrari GM, Klersy C et al. Prognostic value of T-wave alternans in patients with heart failure due to nonischemic cardiomyopathy: results of the ALPHA Study. J Am Coll Cardiol 2007; 50(19):1896-1904.
- Chan PS, Kereiakes DJ, Bartone C et al. Usefulness of microvolt T-wave alternans to predict outcomes in patients with ischemic cardiomyopathy beyond one year. Am J Cardiol 2008; 102:280-284.
- Gold MR, Ip JH, Costantini O et al. Role of microvolt T-wave alternans in assessment of arrhythmia vulnerability among patients with heart failure and systolic dysfunction: primary results from the T-wave alternans sudden cardiac death in heart failure trial substudy. Circulation 2008; 118(20):2022-8.
- Chow T, Kereiakes DJ, Onufer J et al. Prognostic value of microvolt T-wave alternans in patients with moderate ischemic left ventricular dysfunction: results from the MASTER II trial. J Am Coll Cardiol 2008; 51(10):A17.
- Chow T, Kereiakes DJ, Onufer J et al. Does microvolt T-wave alternans testing predict ventricular tachyarrhythmias in patients with ischemic cardiomyopathy and prophylactic defibrillators? The MASTER (Microvolt T Wave Alternans Testing for Risk Stratification of Post-Myocardial Infarction Patients) trial. J Am Coll Cardiol 2008; 52(20):1607-15.
- Leino J, Verrier RL, Minkkinen M et al. Importance of regional specificity of T-wave alternans in assessing risk for cardiovascular mortality and sudden cardiac death during routine exercise testing. Heart Rhythm. 2011 Mar;8(3):385-90. Epub 2010 Nov 5.
- Selvaraj RJ, Suszko A, Subramanian A et al. Microscopic systolic pressure alternans in human cardiomyopathy: noninvasive evaluation of a novel risk marker and correlation with microvolt R-wave alternans. Heart Rhythm. 2011 Feb;8(2):236-43. Epub 2010 Oct 13.
- Verrier RL, Nieminen T, Josephson ME. Antiarrhythmic drug effects on microvolt T-wave alternans: measurement nuisance of indicator of therapeutic action? J Cardiovasc Electrophysiol. 2010 Nov;21(11):E79. doi: 10.111/j/1540-8167.2010.01901.x. Epub 2010 Sep 14.
- Nieminen T, Verrier RL. Usefulness of T-wave alternans in sudden death risk stratification and guiding medical therapy. Ann Noninvasive Electrocardiol. 2010 Jul;15(3):276-88.
- Gupta A, Hoang DD, Karliner L et al. Ability of microvolt T-wave alternans to modify risk assessment if ventricular tachyarrhythmic events: a meta-analysis. Am Heart J. 2012 Mar; 163(3):354-64.
- Merchant FM, Ikeda T, Pedretti RF et al. Clinical utility of microvolt T-wave alternans testing in identifying patients ate high or low risk of sudden cardiac death. Heart Rhythm. 2012 Mar 8. [Epub ahead of print].
- Ikeda T, Yusu S, Yokoyama Y et al. Various patterns of intracardiac electrogram T-wave alternans prior to ventricular tachyarrhythmias in implantable cardioverter-defibrillator patients. Heart Rhythm. 2012 Feb 15. [Epub ahead of print].
- Jackson CE, Myles RC, Tsorlalis IK et al. Profile of microvolt T-wave alternans testing in 1003 patients hospitalized with heart failure. Eur J Heart Fail. 2012 Apr; 14(4):377-86. Epub 2012 Feb 14.
- Monasterio V, Laguna P, Cygankiewicz I et al. Average T-wave alternans activity in ambulatory ECG records predicts sudden cardiac death in patients with chronic heart failure. Heart Rhythm. 2012 Mar; 9(3):383-9. Epub 2011 Oct 22.
- Verrier RL, Klingenheben T, Malik M et al. Microvolt T-wave alternans physiological basis, methods of measurement, and clinical utility: consensus guideline by the International Society for Holter and Noninvasive Electrocardiology. J Am Coll Cardiol. 2011 Sep 20; 58(13):1309-24.
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Policy History:
Date Reason Action
August 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
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and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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