Medical Policy
Effective Date:12/07/2011 Title:Tilt Table Evaluation
Revision Date:10/01/2015 Document:BI324:00
CPT Code(s):93660
Public Statement

 Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Syncope or near-syncope can be caused by a wide variety of disorders.  Most syncopal episodes can be easily classified, and specific testing can be carried out, if required.  For syncope of uncertain origin, in which neurocardiogenic causes is suspected, tilt table testing can be helpful. 
  2. This testing is considered medically necessary and is covered in such cases.
  3. Covered once every 12-month period.
Medical Statement

Tilt table evaluation is considered medically necessary and is covered for the evaluation of recurrent syncopal episodes with a suspected neurocardiogenic origin. 

Codes Used In This BI:

 

93660 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without    pharmacological intervention
Limits
  1. Tilt table testing is considered experimental and investigational for all other indications, including any of the following (not an all inclusive list) because there is little support in the peer-reviewed medical literature for tilt table testing for these indications:

·         Determining the effectiveness of medications in treating recurrent unexplained syncope; or

·         Differential diagnosis of parkinsonian syndromes (e.g., Parkinson`s disease, multiple system atrophy and progressive supranuclear palsy); or

·         Guiding surgical decision-making as well as predicting the clinical response to surgical decompression of Chiari type I-malformation (Chiari drop attacks); or

·         Identifying members with chronic fatigue syndrome and/or evaluating treatment effectiveness of this condition.
Reference
  1. Grubb BP, Kosinski D. Current trends in etiology, diagnosis, and management of neurocardiogenic syncope. Curr Opin Cardiol. 1996;11(1):32-41.
  2. Morillo CA, Klein GJ, Gersh BJ. Can serial tilt testing be used to evaluate therapy in neurally mediated syncope? Am J Cardiol. 1996;77(7):521-523.
  3. Ruiz GA, Scaglione J, Gonzalez-Zuelgaray J. Reproducibility of head-up tilt test in patients with syncope. Clin Cardiol. 1996;19(3):215-220.
  4. Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table testing for assessing syncope. American College of Cardiology. J Am Coll Cardiol. 1996;28(1):263-275.
  5. Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 2: Unexplained syncope. Ann Intern Med. 1997;127(1):76-86.
  6. Voice RA, Lurie KG, Sakaguchi S, et al. Comparison of tilt angles and provocative agents (edrophonium and isoproterenol) to improve head-upright tilt-table testing. Am J Cardiol. 1998;81(3):346-351.
  7. Sutton R, Bloomfield DM. Indications, methodology, and classification of results of tilt-table testing. Am J Cardiol. 1999;84(8A):10Q-19Q.
  8. Kapoor WN. Using a tilt table to evaluate syncope. Am J Med Sci. 1999;317(2):110-116.
  9. Parry SW, Kenny RA. Tilt table testing in the diagnosis of unexplained syncope. QJM. 1999;92(11):623-629.
  10. Bou-Holaigah I, Rowe PC, Kan J, et al. The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA. 1995;274(12):961-967.
  11. Rowe PC, Bou-Holaigah I, Kan JS, et al. Is neurally mediated hypotension an unrecognized cause of chronic fatigue? Lancet. 1995;345(8950):623-624.
  12. Klonoff D. Chronic fatigue syndrome and neurally mediated hypotension. JAMA. 1996;275(5):359-360.
  13. Morillo CA, Klein GJ, Gersh BJ. Can serial tilt testing be used to evaluate therapy in neurally mediated syncope? Am J Cardiol. 1996;77:521-523.
  14. Wessely S. Is neurally mediated hypotension an unrecognized cause of chronic fatigue? Lancet. 1995;345:1112; discussion 1112-1113.
  15. Baschetti R. Chronic fatigue syndrome and neurally mediated hypotension. JAMA. 1996;275(5):359; author reply 360.
  16. Brignole M, Alboni P, Benditt D, et al. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J. 2001;22(15):1256-1306.
  17. Luria DM, Shen WK. Syncope in the elderly: New trends in diagnostic approach and nonpharmacologic management. Am J Geriatr Cardiol. 2001;10(2):91-96.
  18. Faddis MN, Rich MW. Pacing interventions for falls and syncope in the elderly. Clin Geriatr Med. 2002;18(2):279-294.
  19. Tang S, Calkins H, Petri M. Neurally mediated hypotension in systemic lupus erythematosus patients with fibromyalgia. Rheumatology (Oxford). 2004;43(5):609-614.
  20. Timoteo AT, Oliveira MM, Antunes E, et al. Tilt test in elderly patients with syncope of unknown etiology: Experience with pharmacological stimulation with nitroglycerin. Rev Port Cardiol. 2005;24(7-8):945-953.
  21. Gierelak G, Makowski K, Guzik P, et al. Effects of therapy based on tilt testing results on the long-term outcome in patients with syncope. Kardiol Pol. 2005;63(7):1-16; discussion 17-19.
  22. Steinberg LA, Knilans TK. Syncope in children: Diagnostic tests have a high cost and low yield. J Pediatr. 2005;146(3):355-358.
  23. Miller TH, Kruse JE. Evaluation of syncope. Am Fam Physician. 2005;72(8):1492-1500.
  24. Freeman R. Assessment of cardiovascular autonomic function. Clin Neurophysiol. 2006;117(4):716-730. 
  25. Vlahos AP, Tzoufi M, Katsouras CS, et al. Provocation of neurocardiogenic syncope during head-up tilt testing in children: Comparison between isoproterenol and nitroglycerin. Pediatrics. 2007;119(2):e419-e425.
  26. Kirsch P, Mitro P, Mudrakova K, Valocik G. Diagnostic yield of adenosine and nitroglycerine stimulated tilt test in patients with unexplained syncope. Bratisl Lek Listy. 2007;108(6):259-264.
  27. Edfors R, Erdal J, A-Rogvi-Hansen B. Tilt table testing in patients with suspected epilepsy. Acta Neurol Scand. 2008;117(5):354-358.
  28. Mehlsen AB, Mehlsen J. Investigation in suspected syncope. A study of more than 1,174 consecutively referred patients. Ugeskr Laeger. 2008;170(9):723-727.
  29. Straus D, Foster K, Zimmerman F, Frim D. Chiari drop attacks: Surgical decompression and the role of tilt table testing. Pediatr Neurosurg. 2009;45(5):384-389.
  30. Riley DE, Chelimsky TC. Autonomic nervous system testing may not distinguish multiple system atrophy from Parkinson`s disease. J Neurol Neurosurg Psychiatry. 2003;74(1):56-60.
  31. Uno C, Fukuda C, Tanaka N, et al. Study of autonomic dysfunction in patients with obstructive sleep apnea syndrome to head-up tilt test. Rinsho Byori. 2009;57(12):1164-1169.
  32. Oliveira MM, da Silva N, Timóteo AT, et al. Alterations in autonomic response head-up tilt testing in paroxysmal atrial fibrillation patients: A wavelet analysis. Rev Port Cardiol. 2009;28(3):243-257.
  33. Reimann M, Schmidt C, Herting B, et al. Comprehensive autonomic assessment does not differentiate between Parkinson`s disease, multiple system atrophy and progressive supranuclear palsy. J Neural Transm. 2010;117(1):69-76.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.