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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Agency for Healthcare Research and Quality (AHRQ) AHRQ published a technology assessment on thoracic electrical bioimpedance. The technology assessment was commissioned by the Centers for Medicare and Medicaid Services (CMS) for use in coverage policy revisions. The assessment concluded that there was insufficient evidence for meaningful conclusions on the accuracy or clinical usefulness of electrical bioimpedance. The data provided in the available studies suggested that electrical bioimpedance measurements generally correlated similarly with measurements obtained by other testing modalities. Limitations were noted in most reported studies with a scarcity of articles reporting patient outcomes. CMS issued a decision memorandum announcing their intent to refine their national coverage policy regarding TEB for cardiac-related indications. Based on the review of evidence as a whole, CMS decided to continue coverage for all previously covered indications with only minor wording modifications except for general coverage in persons with suspected or known cardiovascular disease due to the paucity of studies evaluating the impact of TEB in these persons. CMS found no clinical evidence to make any changes in the previous non-coverage indications (CMS, 2002).

Additional product names BioZ (CardioDynamics), Cheetah Reliant (Cheetah Medical), AESCULON and ICON (Osypka Medical), LIFEGARD (Analogic), TEBCO (Hemo Sapiens, Inc.) Additional search terms noninvasive hemodynamic monitoring Electrical Bioimpedance for Cardiac Output Measurement - Commercial Medical Management Guideline References and Resources Resources Albert NM, Hail MD, Li J, Young JB. Equivalence of the bioimpedance and thermodilution methods in measuring cardiac output in hospitalized patients with advanced, decompensated chronic heart failure. Am J Crit Care. 2004 Nov;13(6):469-79.

Brown CV, Shoemaker WC, Wo CC, Chan L, Demetriades D. Is noninvasive hemodynamic monitoring appropriate for the elderly critically injured patient? J Trauma. 2005 Jan;58(1):102-7.

Centers for Medicare & Medicaid Services (CMS). Technology Assessment for Thoracic Electrical Bioimpedance.

Agency for Health Care Research and Quality. November 2002. Available at:

http://www.cms.hhs.gov/determinationprocess /downloads/id14TA.pdf. Accessed August 21, 2009.

Cotter G, Moshkovitz Y, Kaluski E, et al. Accurate, noninvasive continuous monitoring of cardiac output by whole-body electrical bioimpedance. Chest. 2004 Apr;125(4):1431-40.

ECRI Institute. Custom Hotline Response. Impedance Cardiography for Cardiac Output Measurement. March 2009.

European Society of Cardiology. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008:

the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J. 2008 Oct;29(19):2388-442.

Hayes, Inc. Directory. Electrical Bioimpedance for the Measurement of Cardiac Output. January 2003. Updated March

2008. Archived November 2008.

Heart Failure Society Of America. Evaluation of patients for ventricular dysfunction and heart failure. J Card Fail. 2006 Feb;12(1):e16-25.

Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the

International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009 Apr 14;53(15):e1-e90. Available at:

http://content.onlinejacc.org/cgi/reprint/53/15/e1.pdf. Accessed September 2, 2009.

Karakitsos DN, Patrianakos AP, Paraskevopoulos A, et al. Impedance cardiography derived cardiac output in hemodialysis patients: a study of reproducibility and comparison with echocardiography. Int J Artif Organs. 2006 Jun;29(6):564-72.

Kaukinen S, et al. Cardiac output measurement after coronary artery bypass grafting using bolus thermodilution, continuous thermodilution, and whole-body impedance cardiography. J Cardiothorac Vasc Anesth. 2003; 17(2): 199-203.

Leslie SJ, McKee S, Newby DE, Webb DJ, Denvir MA. Non-invasive measurement of cardiac output in patients with chronic heart failure. Blood Press Monit. 2004 Oct;9(5):277-80.

Neath SX, Lazio L, Guss DA. Utility of impedance cardiography to improve physician estimation of hemodynamic parameters in the emergency department.Congest Heart Fail. 2005 Jan-Feb;11(1):17-20.

Electrical Bioimpedance for Cardiac Output Measurement - Commercial Medical Management Guideline Peacock WF, Summers RL, Vogel J, Emerman CE. Impact of impedance cardiography on diagnosis and therapy of emergent dyspnea: the ED-IMPACT trial. Acad Emerg Med. 2006 Apr;13(4):365-71.

Raaijmakers E, Faes TJ, Scholten RJ, Goovaerts HG, Heethaar RM. A meta-analysis of three decades of validating thoracic impedance cardiography.Crit Care Med. 1999 Jun;27(6):1203-13.

Shoemaker WC, Wo CC, Chien LC, et al. Evaluation of invasive and noninvasive hemodynamic monitoring in trauma patients. J Trauma. 2006 Oct;61(4):844-53; discussion 853-4.

Smith RD, Levy P, Ferrario CM; Consideration of Noninvasive Hemodynamic Monitoring to Target Reduction of Blood Pressure Levels Study Group. Value of noninvasive hemodynamics to achieve blood pressure control in hypertensive subjects. Hypertension. 2006 Apr;47(4):771-7.

Stout CL, Van de Water JM, Thompson WM et al.. Impedance cardiography: can it replace thermodilution and the pulmonary artery catheter? Am Surg. 2006 Aug;72(8):728-32; discussion 733-4.

Suttner S, Schollhorn T, Boldt J, Mayer J, Rohm KD, Lang K, Piper SN. Noninvasive assessment of cardiac output using thoracic electrical bioimpedance in hemodynamically stable and unstable patients after cardiac surgery: a comparison with pulmonary artery thermodilution. Intensive Care Med. 2006 Dec;32(12):2053-8.

Van De Water JM, Dalton ML, Parish DC, Vogel RL, Beatty JC, Adeniyi SO. Cardiopulmonary assessment: is improvement needed? World J Surg. 2005;29 Suppl 1:S95-8.

Van De Water JM, et al. Impedance cardiography: the next vital sign technology? Chest. 2003;123(6):2028-33.

Velmahos GC, Demetriades D, Shoemaker WC, et al. Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial. Ann Surg. 2000;232:409-418.

History/Updates Policy updated with no changes to the coverage rationale. Coding reviewed with no changes. CMS 10/1/2009 information updated. Policy 2008T0346E archived.

Policy Reformatted. No change in coverage rationale. CMS information updated. Coding Section 1/16/2009 Reviewed, removed CPT Codes 93720, 93721, 93722, 93799. Resources and References updated.

Electrical Bioimpedance for Cardiac Output Measurement 2007T0346D archived.

Policy update. CMS information updated. Policy 2004T0346C archived.

8/16/2007 Reviewed for Medicare Coverage. Medicare Decision Memo CAG-00001R for Electrical 4/13/2005 Bioimpedance for Cardiac Output Monitoring Added LMRP note to Medicare section. No change in coverage.

6/7/2004 Coding Section reviewed by the Reimbursement Medical Policy Operations Manager and no changes 4/29/2004 or additions suggested.

Yearly update. Additions/revisons in multiple sections. No change in coverage rationale.

4/15/2004 Electrical Bioimpedance for Cardiac Output Measurement - Commercial Medical Management Guideline

–  –  –

Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Codes 93701 Bioimpedance, thoracic, electrical

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.

Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Electrical Bioimpedance for Cardiac Output Measurement - Commercial Medical Management Guideline TITLE: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Authorized By: Medical Management Guideline Committee

Adoption Date: 06/29/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.


This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supersede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

–  –  –

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Commercial Medical Management Guideline Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.

Coverage Rationale Functional electrical stimulation (FES), a form of neuromuscular electrical stimulation, is proven for rehabilitation of

paralyzed lower limbs in persons with spinal cord injury (SCI) with all of the following characteristics:

• intact lower motor units (L1 and below) (both muscle and peripheral nerves)

• persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently;

• persons who demonstrate brisk muscle contraction to NMES and have sensory perception of electrical stimulation sufficient for muscle contraction;

• persons who possess high motivation, commitment and cognitive ability to use such devices for walking;

• persons who can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;

• persons who can demonstrate hand and finger function to manipulate controls;

• persons with at least 6-month post recovery spinal cord injury and restorative surgery;

• persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and

• persons who have demonstrated a willingness to use the device long-term.

Functional electrical stimulation is unproven for the treatment of disuse muscle atrophy in spinal cord injury (SCI) persons in the absence of a spinal rehabilitation program. The type of NMES used to enhance the ability to walk in SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. The use of NMES/FES for walking in SCI patients is intended for persons who have completed a training program including regular sessions of physical therapy with the device. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. The physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program; this service cannot be done unattended. The goal of physical therapy is to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy. A low to moderate level of evidence indicates that functional electrical stimulation promotes bone remineralization and prevents and reverses muscular atrophy but further studies are needed to confirm these benefits.

Neuromuscular electrical stimulation (NMES) is proven for:

A. Treatment of disuse muscle atrophy if:

• the nerve supply to the muscle is intact; and

• the disuse muscle atrophy is not of neurological origin but originates from conditions such as casting, splinting or contractures.

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