Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Palpitations, Sinus Bradycardia, Heart murmur.
Treatment: Color-flow Doppler echocardiography in adults (code 93325- TC).
The insurer denied coverage for color-flow Doppler echocardiography in adults (code 93325- TC). The denial is overturned.

This is a female patient who was seen by cardiology. She was complaining of a 1 week history of palpitations, nausea and lightheadedness. She had a sensation of her heart pounding, which was most pronounced when she laid down to go to sleep. She occasionally felt her heart flutters for about 3 seconds while she was at rest. This was not associated with other symptoms. 

The patient exercises twice weekly and does not complain of any symptoms when she is exercising. Recently she was at lunch and felt acutely nauseated and lightheaded, to the point that she felt that she was going to pass out. She indicated that she's under a lot of stress. She has no family history of premature coronary disease or sudden cardiac death. She did say that her grandfather died "early," so she wanted to be careful. She saw a cardiologist several years ago for a heart murmur which was determined to be a benign systolic ejection murmur. Her vital signs were blood pressure (BP) 112/69, pulse 62, temperature 97.7 and oxygen saturation 100%. No abnormalities were described on her physical exam. An electrocardiogram (EKG) showed sinus bradycardia; there was possible left atrial enlargement and left axis deviation. The physician's assessment stated that her recent episode of her heart pounding while she was lying down to go to sleep is likely due to a combination of increased stress, lack of sleep and possibly perimenopausal symptoms. The consultant thought the patient likely has a healthy heart but he would like her to have an echocardiogram to evaluate for structural heart disease as well as a stress test before he increases her exercise regimen. The cardiologist thought that her episode of nausea and lightheadedness may have been associated with a transient drop in blood pressure. An echocardiogram was done and the conclusions listed were left ventricular wall motion was normal and left ventricular ejection fraction (LVEF) was 65%, the right ventricle was normal and there was no pericardial effusion. A stress test was also done. The patient exercised for 13 minutes and 30 seconds which represented 147% of her expected exercise duration. She developed no symptoms during the test. The stress EKG was negative for ischemia. The stress echocardiogram was also negative for ischemia.

The main goal of echocardiographic imaging is to define the etiology, mechanism, severity, and impact of the regurgitant lesion on remodeling of the cardiac chambers. Color flow Doppler is widely used for the detection of regurgitant valve lesions and is the primary method for assessment of regurgitation severity. Experience has shown that attention to these three components of the regurgitation lesion by color Doppler-as opposed to the traditional regurgitant jet area alone with its inherent limitations, significantly improves the overall accuracy of assessment of regurgitation severity.

This patient presented to a Cardiologist to be evaluated for several vague and nonspecific symptoms. The color flow Doppler echocardiogram was an appropriate test to rule out structural heart disease and also to serve as a baseline if further symptoms develop. Ruling out structural heart disease is useful since it allows the physician to focus on other causes of the patient's symptoms. Color flow Doppler was the best treatment for this patient at this time. Color-flow Doppler echocardiography is likely to be more beneficial than any standard treatment or procedure.

The carrier's denial of coverage for color-flow Doppler echocardiography in adults (code 93325- TC) should be overturned.