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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that echocardiography is indicated in the evaluation of derangements of valvular, myocardial 
and pericardial structure and function. The general applications for coverage include: 
 
Transthoracic Echocardiogram 
 
INDICATIONS: 
 
Ventricular Function, Cardiomyopathies and Heart Failure 
1. "When the etiology is in doubt, echocardiography can document or rule out the common cardiac causes 
of pulmonary congestion left-sided valvular disease, depressed systolic or diastolic function, and 
cardiomyopathy. In this regard, echocardiography is the preferred initial diagnostic test when the 
history, physical examination, and routine laboratory tests suggest (or cannot eliminate) cardiac 
disease." (ACC/AHA/ASE 2003 Guideline Update, pg. 35) 
2. "Echocardiography is recommended for patients with edema with clinical signs of elevated central 
venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot 
be estimated with confidence and clinical suspicion of heart disease is high." TTE is also recommended 
for patients experiencing "dyspnea with clinical signs of heart disease."(ACC/AHA/ASE 2003 
Guideline Update, pg. 37) 
3. "Echocardiography is not recommended in patients with edema when the jugular venous pressure does 
not appear to be elevated." (ACC/AHA/ASE 2003 Guideline Update, pg. 35). 
 
Hypertensive Cardiovascular Disease 
1. Evaluating the cardiac effects of systemic hypertension (ACC/AHA/ASE 2003 Guideline Update, pg. 
42) 
2. In young individuals and in individuals with borderline hypertension, the decision to commit to long-
term antihypertensive therapy may be determined by the presence of left ventricular hypertrophy and 
/or left ventricular mass calculation. 
 
Acute Myocardial Infarction and Coronary Insufficiency 1. Evaluation of regional motion, systolic thickening perturbations and mural thinning 
2. Evaluation of right ventricular ischemia and/or infarction 
3. Diagnosis or evaluation of complications of acute infarction (e.g., mural thrombi, papillary muscle 
dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) 
4. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated 
by the acute clinical course. The medical record should document the medical necessity of the 
frequency for TTE assessment. 
5. "Evaluation of chest pain in patients with suspected acute myocardial ischemia, when baseline ECG and 
other laboratory markers are nondiagnostic and when study can be obtained during pain or within 
minutes after its abatement" is recommended in the ACC/AHA/ASE 2003 Guideline Update. 
6. Diagnosis of acute myocardial infarction when the clinical history and ECG findings are nondiagnostic. 
(ACC/AHA/ASE 2003 Guideline Update, pg. 15) 
 
Exposure to Cardiotoxic Agents (chemotherapeutic and external) 
An initial complete TTE may be performed prior to first administration of the agent with the frequency of 
repeat studies determined by the patient's clinical course and the toxicity profile of the agent being 
administered, although tests performed bimonthly during chemotherapy and at six (6) months following 
therapy are generally considered medically appropriate. 
 
Cardiac Transplant and Rejection Monitoring 
1. TTE is an integral part of the cardiac donor-selection and donor-recipient matching process. Evaluation 
focuses on analysis of ventricular function and valvular integrity. 
2. TTE in the management of allograft recipients is typically performed weekly for the first four to eight 
(4-8) weeks following transplant, with reduced frequency over time. Absent acute rejection episodes, 
approximately two (2) TTE examinations are typically performed yearly in chronic transplant 
recipients. TTE of cardiac allografts is most appropriately serially performed at transplant centers by 
examiners with expertise in the management of cardiac allograft recipients. Uses in excess of the 
generally accepted frequency will be expected to have appropriate medical necessity documentation 
provided. 
 
Native Valvular Heart Disease 
1. TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its 
effect upon global myocardial function. 
2. In some patients, Doppler echocardiography is the only noninvasive method capable of identifying the 
cause of a heart murmur. (ACC/AHA/ASE 2003 Guideline Update, pg. 7) 
3. Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, it is not 
medically necessary to repeat these examinations more frequently than annually. When the patient's 
clinical status shows evidence of change or the plan of care includes consideration for imminent 
valvular surgery, more frequent exams may be necessary. 
 
Prosthetic Heart Valves (Mechanical & Bio-prostheses) 
TTE assessment after prosthetic valve implant to establish a baseline structural and hemodynamic profile with 
reassessment following convalescence (3-6 months). Thereafter, re-evaluation of patients with suspected 
dysfunction, thrombosis or a change in clinical status or symptoms is indicated. 
 
 Acute Endocarditis 
1. Diagnostic and evaluation of suspected endocarditis or complications or sequelae of acute infective 
endocarditis. 
2. Examination frequency in the acute phase of illness is dictated by the individual clinical course. When 
the acute process has been stabilized, the frequency of serial TTE evaluation will be determined by the 
residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic 
valvular dysfunction and/or normally functioning prosthetic valves. 
 
Pericardial Disease 
1. Detection and quantitation of the amount of pericardial effusion. 
2. To characterize the hemodynamic consequences of pericardial fluid accumulation. 
3. As an adjunct during the removal of pericardial fluid and creation of pericardial windows. 
4. Diagnosis of pericardial constriction and differentiating it from restrictive myocardial disease (may 
require Doppler). 
5. The acute clinical status will dictate examination frequency. In a patient with evolving pericardial 
pathology, a limited focused TTE exam may be appropriate. 
 
Abnormalities of the Great Vessels 
1. Evaluation of acute or chronic aortic pathology (Note: TEE is often a more determinative study unless 
images suitable for serial quantitation can be obtained by TTE). 
2. Routine (yearly) evaluation is indicated in patients with severe aortic stenosis or regurgitation, in whom 
the information obtained will be used in determining or modifying the plan of care. 
3. With ascending aortic dilatation or aneurysms, a focused limited follow-up exam to serially measure 
ascending aortic diameters may be indicated. 
4. Evaluation of the main pulmonary artery segment and the proximal right and left pulmonary arteries. 
5. Evaluation of the vena cavae and diagnosing congenital and acquired abnormalities such as vena caval 
thrombosis, vena caval dilation, and thrombosis or extension of tumors from the inferior vena cava to 
the right-heart chambers. 
 
Congenital Heart Disease 
1. TTE with Doppler hemodynamic measurements for diagnosis and noninvasive serial assessment of 
most congenital heart diseases. 
2. When the disease process and therapy are stable, assessment more often than annually requires medical 
necessity documentation. 
3. In asymptomatic patients following repair of ASD, PFO, VSD or PDA follow up examination is only 
indicated within the first year after correction. 
 
Suspected Cardiac Thrombi and Embolic Sources 
TTE is indicated for the evaluation for cardiovascular source of embolic events (PFO/ASD, atrial or ventricular 
thrombus, intracardiac tumor) in evaluation for patients with abrupt occlusion of a major peripheral or visceral 
artery or for with neurological events without evidence of cerebrovascular disease or other obvious cause. 
 
 Cardiac Tumors and Masses 
1. Diagnosis and assessment of cardiac tumors. 
2. Serial TTEs may be medically necessary to monitor tumor size or tumor recurrence. 
 
Critically Ill and Trauma Patients 
1. Diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion, or pericardial effusion. 
2. Assessment of volume status. 
3. The frequency of these typically acute studies will be dictated by the clinical circumstances. 
 
Arrhythmias and Palpitations 
1. Transthoracic echocardiography is useful in defining cardiac function in which arrhythmias occur and 
may be useful in the management of cardiac arrhythmias. Some arrhythmias are frequently associated 
with underlying organic heart disease or may predispose the patient to hemodynamic deterioration. 
Atrial fibrillation and atrial flutter are examples of arrhythmias in which echocardiography may be 
appropriate to assess the underlying disorder. Echocardiographic studies are appropriate only when 
there is evidence of heart disease. 
2. Palpitations without evidence of arrhythmias, or minor arrhythmias (e.g., isolated APC's or VPC's) 
without evidence of heart disease, are not covered indications for transthoracic echocardiography. 
 
Syncope 
In the initial evaluation of syncope and when other findings are suggestive of valvular heart disease or 
obstructive cardiomyopathy. 
 
Pulmonary 
To assess right ventricular size and performance, and quantify the severity of pulmonary hypertension using 
Doppler flow in unexplained pulmonary hypertension, and pulmonary emboli with suspected right atrial or 
right ventricular sources of emboli. 
 
Contrast Echocardiography 
Contrast echocardiography is indicated when a conventional study has failed to provide adequate and critically 
needed information on left ventricular function. A contrast agent is considered medically necessary when it is 
used to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast study 
is inadequate or suboptimal, and for whom the LV function information is essential to the management of the 
patient. Contrast is indicated when more than two (2) contiguous segments of the left ventricular border are not 
visualized. 
 
LIMITATIONS: 
- 1. Echocardiography performed for screening purposes is not covered. Screening includes testing 
performed on patients who present with risk factors (including the risk factor as having a positive 
family history, e.g., familial history of Marfan's disease). A screening service for high-risk patients is 
considered good medical practice but is not covered by Medicare. When the result of the test is 
abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial 
screening test must be listed as screening, even though the result of the screening test may be a covered 
condition. The following indications (#2-15) are deemed to be not medically necessary and are therefore not 
reimbursable: 
 
2. Routine (yearly) evaluation of asymptomatic patients with corrected ASD, VSD or PDA more than one year 
after successful correction. 
 
3. Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no 
change in clinical status. 
 
4. Routine (yearly) re-evaluation of an asymptomatic patient with mild native aortic stenosis or mild-moderate 
native mitral stenosis and no change in clinical status. 
 
5. Routine (yearly) re-evaluation of native valvular regurgitation in an asymptomatic patient with mild 
regurgitation, no change in clinical status and normal left ventricular size. 
 
6. Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular 
dysfunction and no change in clinical status. 
 
7. Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change 
in clinical status. 
 
8. Routine (yearly) evaluation of hypertrophic cardiomyopathy in a patient with no change in clinical status. 
 
9. Patients who have isolated APC or VPC without other evidence of heart disease. 
 
10. Evaluation of LV function with prior ventricular function within the past year with normal (such as prior 
echocardiogram, left ventriculogram, SPECT, cardiac MRI) in patients in whom there has been no change in 
clinical status. 
 
11. Initial evaluation of patient with suspected pulmonary embolism in order to establish diagnosis. 
 
12. Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of 
bacteremia or new murmur. 
 
13. Re-evaluation of a patient with known hypertensive heart disease without a change in clinical status. 
 
14. Routine evaluation of patients with systemic hypertension without suspected hypertensive heart disease. 
 
15. Evaluation of a patient with atrial fibrillation/flutter for left atrial thrombus or spontaneous contrast when a 
decision has been made to anticoagulate and not to perform cardioversion. 
 
[Items 2-15, see ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for 
Transthoracic and Transesophageal Echocardiography, JACC 2007]. 
 
Follow-up Studies or Limited Studies 
 
INDICATIONS AND LIMITATIONS 
 
A complete study includes a full evaluation of all aspects of the heart, including the cardiac chambers, valves, 
blood flow, and great vessels. The images are reviewed, measured, analyzed and interpreted by the physician. 
A report is prepared for the patient's record. When a less than complete examination is performed for the 
purpose of evaluation of one specific cardiac problem, or region of the heart, the service performed is reported as follow-up or limited studies. When a limited service is performed, or the patient's condition requires only a 
limited examination, these codes must be used to indicate the appropriate service. 
 
Examples of appropriate use of a follow-up study of a patient with pericardial effusion following heart surgery, 
to evaluate progression or resolution of the effusion; or a serial evaluation of left ventricular function during 
antineoplastic chemotherapy. 
 
Examples of appropriate use of recording tricuspid regurgitant velocity in order to estimate pulmonary artery 
systolic pressure; or sequential evaluation of the transmitral velocity profile in a patient with mitral stenosis, in 
order to evaluate for a change in gradient or valve area. 
 
Doppler Color Flow Velocity Mapping 
 
INDICATIONS AND LIMITATIONS 
Spectral Doppler echocardiography and Doppler color flow-velocity mapping may be necessary in addition to 
an echocardiogram when the examination could contribute significant information to the patient's condition or 
treatment plan. Typically, Doppler is indicated in the evaluation of some heart murmurs, valvular problems, 
shunts, suspected congenital heart disease, complications of myocardial infarction, or cardiomyopathy. Doppler 
should be medically necessary for the evaluation and management of the patient. 
 
"Color/spectral Doppler may not be useful or appropriate in certain relatively small and well-defined patient 
populations when there is a recent comprehensive examination and the test is being ordered for re-evaluation of 
a limited problem." (ASE comment). 
 
The use of the Doppler is inherent in the ultrasonic cardiac evaluation. However, if the test reports fail to 
document the use of this technique to assess these structures and function (e.g., measurement of valvular 
insufficiency or stenosis, myocardial diastolic function, etc. as described by the ASE), or if the medical records 
fail to document that the examination was "clinically necessary" (e.g., follow-up of pericardial effusion size) 
then the Doppler portion of the test may be considered medically unnecessary and denied. 
 
Limited Capability Ultrasound Scanners 
 
INDICATIONS AND LIMITATIONS 
 
Some small scanners have more limited capabilities and lack either the permanent recording capabilities or 
some of the functional capabilities needed to perform a complete examination. Such a study may be quite 
useful as an extension of the physical examination. However, an examination that does not meet the standards 
required for a complete diagnostic echocardiographic examination - whether performed with a "conventional" 
scanner or a limited capability ultrasound scanner - will not be recognized as a valid echocardiographic service 
and will be non-covered. 
 
Stress Echocardiography 
 
Stress Echocardiography may be necessary when the evaluation could contribute significant information to the 
patient's condition or treatment plan. A non-imaging stress test focuses on the hemodynamic and 
electrocardiographic responses to stress. To enhance the diagnostic specificity, the stress test may be combined 
with echocardiographic imaging or scintigraph imaging. A contrast agent may be used with echocardiographic 
imaging to enhance endocardial visualization and diagnostic accuracy. When two (or more) imaging studies 
(e.g., ultrasound and scintigraphy) are billed without a supporting clinical indication for each, one of the 
services will be denied as not medically necessary. This section addresses the echocardiographic imaging that 
is done in association with a stress test. 
 INDICATIONS 
 
Stress echocardiography may be indicated in the care of patients with real or suspected ischemic heart disease 
in the following clinical settings: 
1. To detect coronary artery disease in patients presenting with chest pains including atypical chest pains 
and exertional dyspnea when the suspicion of CAD is high. 
2. To assess prognosis and functional capacity in patients following an acute myocardial infarction. 
3. To evaluate the extent of exercise induced ischemia in patients who have had a revascularization 
procedure (PCTA, stent or coronary bypass) or patients who have known CAD disease. 
4. In women, stress imaging has been recommended as the "initial test." 
5. To evaluate a prior nondiagnostic or abnormal ECG exercise test as a substitute for a nuclear perfusion 
study. 
6. To evaluate patients who are at high risk for myocardial infarction prior to a scheduled major surgical 
procedure (e.g., aneurysm, vascular surgery, surgeries with large volume shifts, etc.) or transplant 
procedure. 
7. To evaluate patients presenting with various arrhythmias (atrial and/or ventricular) or syncope (near or 
pre), when the suspicion of occult coronary artery disease is high. 
8. To evaluate patients when an indicated standard exercise ECG is likely to be non-diagnostic, including 
patients with an abnormal resting ECG, orthostatic or hyperventilation induced ECG changes, 
nonspecific ST-T abnormalities due to ventricular hypertrophy drugs or associated intraventricular 
conduction defect. 
9. To assess myocardial viability (hibernating myocardium) for planned revascularization or functional 
significance of coronary lesions (if not already known) in planning percutaneous transluminal coronary 
angioplasty. 
10. To evaluate cardiomyopathy when the evaluation could reasonably be expected to contribute significant 
information regarding the patient's condition or treatment plan. 
11. To evaluate ventricular dysfunction due to post-transplant rejection when the evaluation could 
reasonably be expected to contribute significant information regarding the patient's condition or 
treatment plan. 
12. To evaluate congenital heart disease, when stress echocardiography helps to determine systemic and 
right ventricular function at rest and following stress and the presence of any other structural 
abnormalities, including valvular lesions that may be accentuated with stress. 
13. Additionally the test may combine with Doppler intervention to evaluate exercise hemodynamics in 
patients with mitral stenosis, mitral regurgitation, pulmonary hypertension, aortic stenosis/regurgitation, 
prosthetic valves and other conditions where symptoms suggest a more severe impairment than the 
assessment done at rest. 
14. Dobutamine stress echo may be indicated to detect low gradient, low output (aortic stenosis) or 
clinically silent transplant coronary disease. 
LIMITATIONS 
1. Stress echocardiography used as a screening test for ischemic heart disease in a patient without signs or 
symptoms is not covered. 
2. "An echocardiographic study is not indicated when the pathology and/or systolic ventricular function 
have been adequately defined by other techniques, making the echocardiographic study redundant." 
(ACC/AHA/ASE 2003 Guideline Update, pg. 5). 
3. Since echocardiography, nuclear testing, magnetic resonance imaging (MRI), and positron emission 
tomography can yield overlapping if not identical information, often with similar or comparable 
accuracy, when two or more of these tests provide equivalent information, one (but not both/all) will be 
covered when medically necessary. 4. Stress tests by multiple modalities (e.g. stress echocardiography, nuclear SPECT) for the same clinical 
event are covered only if the preceding test was inconclusive or uninterpretable. 
5. Studies with or without contrast will be considered a single study, whether performed on the same or 
subsequent days. 
6. Contrast echocardiography is not covered when used to evaluate perfusion. Contrast is not indicated 
unless more than two (2) contiguous segments of the left ventricular border are not visualized. 
7. A stress test must be ordered by a physician or qualified non-physician provider. 
8. The resting 12 lead EKG and rhythm strip are considered to be part of the stress test. These services are 
not separately reimbursable. 
9. The initiation of an intravenous line and infusion of a pharmacological agent are considered to be a part 
of the test and are not separately reimbursable. 
3-Dimensional Echocardiography 
 
INDICATIONS AND LIMITATIONS 
 
Three-dimensional echocardiography performed in conjunction with transthoracic echocardiography is 
indicated for: 
1. Pre-operative planning in patients who will be having surgery to repair mitral valve prolapse (in 
addition to a diagnosis for a pre-operative examination, a secondary diagnosis of mitral valve prolapse 
is required on the claim). 
2. Monitoring the mitral valve area in patients with moderate to severe mitral stenosis. 
Three-dimensional echocardiography provides improved calculation of volumetric studies when compared to 
2D echocardiography. However, its value in affecting clinical outcomes is not yet proven and is therefore not 
considered medically necessary. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33577: Transthoracic 
Echocardiography (TTE). 

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.