Effective Date: 12/07/2011
Title: Tilt Table Evaluation
Revision Date: 10/01/2015
CPT Code(s): 93660
will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
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.
This testing is considered
medically necessary and is covered in such cases.
Covered once every 12-month
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:
Evaluation of cardiovascular function with tilt table evaluation, with
continuous ECG monitoring and intermittent blood pressure monitoring, with or
without pharmacological intervention
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
the effectiveness of medications in treating recurrent unexplained syncope;
diagnosis of parkinsonian syndromes (e.g., Parkinson`s disease, multiple system
atrophy and progressive supranuclear palsy); or
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.
Syncope and pre-syncope are commonly classified as being of either
cardiovascular or non-cardiovascular origin. Cardiovascular mechanisms
incorporate mechanisms resulting from structural cardiac and/or vascular disease
as well as a diverse group of neurally mediated reflex (cardio-neurogenic)
syncopal syndromes. The non-cardiovascular mechanisms encompass organic central
nervous system disease, metabolic/endocrine disturbances, and psychiatric
Among all causes of syncope, however, the neurally mediated reflex syncopal
syndromes are believed to be the most common, although only `emotional` or
`vasovagal` faint occurs frequently. Until recently, the diagnosis of neurally
mediated reflect syncope has relied primarily on suspicions raised in the
medical history in conjunction with the exclusion of other etiologies by
application of a variety of medical tests. Head-up tilt table testing has
substantially changed this picture.
Currently it is believed that the development of hypotension and bradycardia in
conjunction with sustained upright posture is at least in part comparable to the
mechanisms triggered by afferent neural signals from central cardiopulmonary
mechanoreceptors that occur during the `emotional` faint. Consequently, there
has been considerable interest in the clinical application of head-up tilt
testing as a means of assessing susceptibility to neurally mediated reflex
The American College of Cardiology published a consensus statement on tilt table
testing that concluded that such testing had a valuable role in the clinical
evaluation of patients with syncope of uncertain origin. In addition, the
European Society of Cardiology Task Force on Syncope guidelines state that tilt
table testing is indicated for diagnostic purposes with certain specific
indications. A guideline on the diagnosis of syncope of the American College
of Physicians’ Clinical Efficacy Assessment Project also recommends tilt-table
testing. However, none of the guidelines states that tilt-table testing can
obviate a thorough cardiac work-up if a cardiac cause of syncope is possible.
Nor do they identify any specific clinical decision that is altered by the use
of the tilt-table test. The guidelines do not address any differences in
treatment approach between patients diagnosed with neurocardiogenic syncope
based on clinical symptoms alone, based on tilt table testing, or arrived at by
exclusion of other possible causes.
randomized clinical trials evaluating dual-chamber pacemakers as a treatment for
neurocardiogenic syncope in patients with refractory syncope have been
published. The entry criteria for these clinical trials required that the
patient have a cardioinhibitory or bradycardic response as assessed by tilt
table testing. This criterion exists because the scientific rationale for this
treatment is that the pacemaker corrects the slow heart rhythm that is
presumably the cause of the syncope in this subset of patients.
In the North American Vasovagal Pacemaker Study, 54 patients were evenly
randomized to receive a pacemaker or no pacemaker. The trial was terminated
early because of a strong effect observed in favor of pacing. Recurrent syncope
occurred in 19/27 (70%) of no-pacemaker patients and in 6/27 (22%) of pacemaker
patients. The relative risk reduction, as calculated through survival analysis,
In another study of pacemakers by Sutton and co-workers, 42 patients were
randomized to receive pacemaker or no pacemaker. One of 19 (5%) of patients in
the pacemaker group experienced recurrent syncope, compared with 14/23 (61%) of
patients in the no-pacemaker group.
Several concerns have been expressed about the results of these clinical trials
of pacemaker therapy, such as the lack of a sham control, a no-treatment control
group (as opposed to an active no-pacemaker control group), the small sample
sizes, and the highly select nature of the populations studied. With respect to
tilt-table testing, concern has been expressed as to whether the
cardioinhibitory response elicited on a tilt-table test corresponds to the
cardioinhibitory response of the syncopal episode.
Evidence is lacking as to whether cardiac pacing is effective among patients
with other types of tilt table test responses or among patients with negative
tilt-table tests. Thus, it is unknown whether the tilt-table test is actually a
necessary component of the selection criteria for a pacemaker. However, given
the invasiveness and complexity of pacemaker treatment for syncope, it would be
reasonable to incorporate the screening criteria used in the clinical trials
reviewed above. Thus, for patients whose frequency, severity, and refractoriness
to treatment merit consideration for pacemaker therapy, tilt-table testing to
evaluate cardioinhibitory response may be considered medically necessary.
While vasovagal syncope was previously thought to be confined to younger
patients, it is now being diagnosed more frequently in the elderly. Head up
tilt testing has substantially contributed to our understanding of the
pathophysiology of vasovagal syncope. Nitroglycerin is now routinely
administered during the test. People with typical symptoms do not need tilt
testing, but the test is often required in patients with atypical features,
seizure activity, and in those with occupational issues. It is more often
needed in older patients. (Tan, 2009). Carew et al reported that a 10 minute
tilt test is inadequate to differentiate postural tachycardia syndrome from
vasovagal syncope (Carew, 2009). An Indian survey indicated that a lack of
standardization of testing in children has caused pediatric electrophysiologists
to use the tilt test progressively less often (Batra, 2008).
Grubb BP, Kosinski D. Current
trends in etiology, diagnosis, and management of neurocardiogenic syncope.
Curr Opin Cardiol. 1996;11(1):32-41.
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.
Ruiz GA, Scaglione J,
Gonzalez-Zuelgaray J. Reproducibility of head-up tilt test in patients with
syncope. Clin Cardiol. 1996;19(3):215-220.
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.
Linzer M, Yang EH, Estes NA 3rd,
et al. Diagnosing syncope. Part 2: Unexplained syncope. Ann Intern Med.
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.
Sutton R, Bloomfield DM.
Indications, methodology, and classification of results of tilt-table
testing. Am J Cardiol. 1999;84(8A):10Q-19Q.
Kapoor WN. Using a tilt table to
evaluate syncope. Am J Med Sci. 1999;317(2):110-116.
Parry SW, Kenny RA. Tilt table
testing in the diagnosis of unexplained syncope. QJM. 1999;92(11):623-629.
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.
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.
Klonoff D. Chronic fatigue
syndrome and neurally mediated hypotension. JAMA. 1996;275(5):359-360.
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.
Wessely S. Is neurally mediated
hypotension an unrecognized cause of chronic fatigue? Lancet. 1995;345:1112;
Baschetti R. Chronic fatigue
syndrome and neurally mediated hypotension. JAMA. 1996;275(5):359; author
Brignole M, Alboni P, Benditt D,
et al. Guidelines on management (diagnosis and treatment) of syncope. Eur
Heart J. 2001;22(15):1256-1306.
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.
Faddis MN, Rich MW. Pacing
interventions for falls and syncope in the elderly. Clin Geriatr Med.
Tang S, Calkins H, Petri M.
Neurally mediated hypotension in systemic lupus erythematosus patients with
fibromyalgia. Rheumatology (Oxford). 2004;43(5):609-614.
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
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
Steinberg LA, Knilans TK. Syncope
in children: Diagnostic tests have a high cost and low yield. J Pediatr.
Miller TH, Kruse JE. Evaluation
of syncope. Am Fam Physician. 2005;72(8):1492-1500.
Freeman R. Assessment of
cardiovascular autonomic function. Clin Neurophysiol. 2006;117(4):716-730.
Vlahos AP, Tzoufi M, Katsouras
CS, et al. Provocation of neurocardiogenic syncope during head-up tilt
testing in children: Comparison between isoproterenol and nitroglycerin.
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.
Edfors R, Erdal J, A-Rogvi-Hansen
B. Tilt table testing in patients with suspected epilepsy. Acta Neurol
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.
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.
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.
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.
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
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.