As a primary care physician who practiced internal medicine for 30 years, I was often frustrated when I was unable to obtain authorization for diagnostic echocardiography to follow my patients with cardiac disease. Prior authorization companies rarely denied ECHO requests for typical cardiac signs or symptoms, but repeating the study a year or two after the initial ECHO was often denied. The rationale for denying the repeat imaging often seemed random and arbitrary. As medical director, I discovered that cardiac guidelines, especially those borrowed from the American College of Cardiology, were not random at all. This post will review the rationale that supports the guideline for repeating echocardiography.
Initial transthoracic echocardiography criteria
Guidelines for approval of initial diagnostic echocardiography are quite broad, as long as the doctor’s office liaison communicates the specific cardiac sign or symptom your patient is having:
CAD/CHF Criteria for an initial ECHO includes chest pain, shortness of breath, palpitations, syncope, a murmur, and signs/symptoms of heart failure.
Valvular criteria for initial ECHO includes stenosis, regurgitation or any other valve abnormality (native or prosthetic valve). Any sign or symptom of suspected endocarditis or valve dysfunction including fever or a new murmur or for clot or vegetation detection.
Wall motion abnormalities such as ejection fraction and Coronary artery disease, including symptoms of CHF, suspected cardiomyopathy, and pre-chemotherapy EF.
Muscular abnormalities including infiltrative disease or papillary muscle abnormalities.
Hypertrophic obstructive Cardiomyopathy in index patient or first degree relatives
New abnormality on an ECG that has not been evaluated.
Miscellaneous: Pericardial Disease, Aortic root or ascending aorta disease, pacemaker insertion complication, pulmonary hypertension, myxomas, and congenital heart disease (repaired or unrepaired).
Repeating transthoracic echocardiography and time-frame criteria
RBM guidelines do not support routine echocardiography for evaluation of clinically stable conditions. The key words are “routine and clinically stable.” If patients are having new or changed signs or symptoms related to their cardiac abnormality, repeat imaging will be approved (according to the frequency time-frame below).
Anytime (if there are changes in signs or symptoms) for CAD (myocardial infarction or acute coronary syndrome), CHF (including new or worsening edema, new or worsening dyspnea, elevated or changing BNP), pericardial disease, prosthetic valve dysfunction or thrombosis, stroke or TIA.
Once a year (regardless of changes in signs or symptoms) for significant valve dysfunction, hypertrophic cardiomyopathy, chronic pericardial effusions, left ventricular contractility dysfunction prior to planning new or change in medical therapy for CHF or to evaluate the effectiveness of on-going treatment, pulmonary hypertension, aortic root dilatation.
Twice a year (if there are new changes in signs or symptoms) for pericardial effusion, new/changed medical therapy for congestive heart failure, hypertrophic cardiomyopathy or any other critical valve disease (when results of the echo will possibly change management.
Exceptions and Inconsistencies: Two RBMs (AIM and NIA) include “hypertension” on their list of indications for initial ECHO in children, whereas a third RBM (eviCore) omits this indication. Refer to specific RBM guideline.
To obtain authorization “right out of the gate” it is essential that providers communicate specific clinical information. For example:
• What is (are) the reason(s) (diagnosis) for requesting the ECHO?
• When was the last ECHO?
• What was the result of that ECHO?
• Does the medical record describe a new or change in clinical features since the last ECHO?
Lesson #26: Physicians seeking follow-up echocardiography for patients with documented valve, muscle or pericardial disease should carefully convey to prior authorization nurses the date and results of previous ECHOs as well as any new changes in signs or symptoms. Paying attention to the time-frame for ECHO as outlined in guidelines from RBMs or cardiology societies will avoid wasting time with denied requests, appeals, and peer-to-peer calls. Always make sure your office PAL (prior authorization liaison) tells the RBM when a repeat ECHO is designed to determine if management should be changed.