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Medical Policy: 02.02.06
Original Effective Date: August 2001
Reviewed: September 2008
Revised: August 2003
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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. 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.
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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT 93025 T-wave alternans testing.
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Selected References:
- A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.
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
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
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affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
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