National Medical Policy

National Medical Policy Subject: Thoracic Electrical Bioimpedance - Outpatient Setting Policy Number: NMP321 Effective Date*: February 2007 Update...
Author: Solomon Nichols
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National Medical Policy Subject:

Thoracic Electrical Bioimpedance - Outpatient Setting

Policy Number:


Effective Date*: February 2007 Updated:

September 2015

This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use


Reference/Website Link


National Coverage Determination (NCD)

Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (20.16):


National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other


MLN Matters Number: MM8197. July 1, 2013. International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs): Use Health Net Policy


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Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2)

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If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.

Current Policy Statement Health Net, Inc. considers thoracic electrical bioimpedance in the outpatient setting investigational due to insufficient evidence in the published, peer-reviewed medical literature to support its use outside the critical care setting.

Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date.

ICD-9 Codes 276.9 401.0-405.99 427.0-427.9 428.0-428.9 429.2 429.4 786.09 996.83 V42.1 V45.01

Electrolyte and fluid disorders not elsewhere classified Hypertensive disease Cardiac dysrhythmias Heart failure Cardiovascular disease, unspecified Functional disturbances following cardiac surgery Other dyspnea and respiratory abnormalities Complications of transplanted heart Heart replaced by transplant Cardiac pacemaker in situ

ICD-10 Codes E78.0-E78.9 E10-E115.9 I47.0-I49.9 I50.1-I50.9

Disorders of lipoprotein Hypertensive disease Cardiac arrhythmias Heart failure

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I97.0-I97.89 R06.00R06.09 T86.20T86.298 Z94.1 Z95.0-Z95.9

Intraoperative and postprocedural complications and disorders of circulatory and / or cardiac system, not elsewhere classified Abnormalities of breathing Complications of heart transplant Heart transplant status Presence of cardiac and vascular implants and grafts

CPT Codes 93701

Bioimpedance, thoracic, electrical

Scientific Rationale Update – September 2014 The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) has updated their ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults (2013). This concludes that no role for periodic invasive or noninvasive hemodynamic measurements has been established in the management of heart failure. The quality of the evidence for thoracic bioimpedance, in the outpatient setting remains limited. It is not known whether this techniques alters management or treatment plans and improve health outcomes in patients with chronic heart failure. Therefore, thoracic bioimpedance in the outpatient setting remain investigational.

Scientific Rationale Update – February 2011 Thoracic electrical bioimpedance, a form of plethysmography, is defined as the electrical resistance of tissue to the flow of current. Changes in bioimpedance, resulting from the pulsatile changes in volume and velocity of blood in the aorta, are inversely proportional to the stroke volume (cardiac output equals the stroke volume times heart rate). The technique of bioimpedance cardiac output monitoring was first described by Kubicek et al. and is based on changes in electrical impedance of the thoracic cavity occurring with ejection of blood during cardiac systole. In the outpatient setting, thoracic bioimpedance has been investigated as a technique to optimize drug therapy in patients with congestive heart failure. Echocardiography, transesophageal echocardiography (TEE), and Doppler ultrasound are other noninvasive methods for monitoring cardiac output. However, there is a paucity of peer-reviewed, well-designed, randomized, controlled or comparative trials with adequate follow-up to determine the safety and efficacy of this technique, outside the critical care setting. Vorwerk et al. (2010) completed a prospective cohort study of adult patients who presented with acute breathlessness to the ED of a large urban teaching hospital. Study patients had their cardio-hemodynamic parameters measured, using a thoracic electrical bioimpedance (TEB) device. The patient's hospital discharge diagnosis was used as the definitive diagnosis to determine whether the underlying cause of acute dyspnea was cardiac or non-cardiac related. The definitive diagnosis was compared with the TEB data and the ED physician's diagnosis. To determine whether cardiohemodynamic parameters, using non-invasive thoracic electrical bioimpedance (TEB), can differentiate between cardiac and non-cardiac causes of acute breathlessness in adult emergency department (ED) patients. 52 patients were recruited into the study, of whom 51 had complete TEB data and were included in

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the analysis. There were statistically significant differences in cardiac output (6.2 vs 7.9, p