BlueCross and BlueShield of Montana Medical Policy/Codes
Tilt Table Testing
Chapter: Medicine: Tests
Current Effective Date: September 24, 2013
Original Effective Date: September 24, 2013
Publish Date: June 24, 2013
Revised Dates: This policy is no longer scheduled for routine literature review and update.
Description

The tilt-table test is used to diagnose neurocardiogenic syncope. The device required for a tilt-table test is a motorized table designed specifically for use in a cardiac catheterization or electrophysiology laboratory. This table differs from tilt-tables used in radiology and physical therapy departments. The tilt-table for syncope testing must change the patient’s position from 0–60º in less than ten seconds, must be able to restore the patient equally quickly to a supine position, and must have proper restraints. The patient is held at a 60° angle for an extended period of time, during which heart rate and blood pressure are monitored and syncope observed should it occur. Syncope is defined as a sudden, transient loss of consciousness, accompanied by loss of postural tone.

The tilt-table test has also been used to classify a patient’s syncope into different categories, which may aid in determining whether a patient is a candidate for insertion of a pacemaker to treat syncope. Based on the heart rate and blood pressure changes observed during the tilt, syncope can be classified as type 1 mixed, type 2A cardioinhibitory, type 2B cardioinhibitory, or type 3 pure vasodepressor.

Policy

Prior authorization for tilt table testing is recommended. Call the Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service Department at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.

Medically Necessary

BCBSMT may consider tilt-table testing medically necessary for any of the following:

  • Patients who have experienced one or more syncopal episodes, whether or not the medical history is suggestive of neurally mediated (vasovagal) origin, AND
    • There is no evidence of structural cardiovascular disease (based on thorough history and physical, 12-lead ECG, echocardiogram and formal exercise testing), OR
    • Structural cardiovascular disease is present, but other causes of syncope have been excluded by appropriate testing; OR
  • Further evaluation of a patient with syncope in whom an apparent cause has been established (e.g., asystole, atrioventricular block), but in whom demonstration of susceptibility of neurally mediated syncope would affect treatment plans; OR
  • Part of the evaluation of exercise-induced or exercise-associated syncope.

Investigational

BCBSMT considers tilt-table testing experimental, investigational and unproven for all other indications including, but not limited to:

  • Differentiating convulsive syncope from seizures,
  • Evaluating patients (especially the elderly) with recurrent unexplained falls,
  • Assessing recurrent dizziness or presyncope,
  • Evaluating unexplained syncope in the setting of peripheral neuropathies or dysautonomias,
  • Follow-up evaluations to assess therapy of neurally mediated syncope,
  • Syncope in which an alternative specific cause has been established and in which additional demonstration of a neurally mediated susceptibility would not alter treatment plans,
  • Identifying patients with chronic fatigue syndrome and/or evaluating treatment effectiveness of this condition.

Federal Mandate

Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

The policy regarding use of the tilt-table test for the diagnosis of syncope was based on a 1997 Blue Cross Blue Shield America Technology Evaluation Center (TEC) Assessment.(4)  That TEC Assessment was based on a prior 1995 TEC Assessment and a review of the literature published from January 1991 through January 1997. The 1997 TEC Assessment concluded that for the diagnosis of syncope, the evaluation of tilt-table testing is limited due to the lack of standardized protocols for the test, poor sensitivity for the diagnosis of neurocardiogenic syncope, and lack of evidence that tilt-table testing improves health outcomes or reduces utilization of other medical resources needed to diagnose or manage syncope. Although tilt-table testing allows confirmation of a diagnosis of neurocardiogenic syncope in many cases, it is not specific enough to rule out life-threatening cardiac causes of syncope, and not sensitive enough to detect most cases of neurocardiogenic syncope.

The American College of Cardiology (3) 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.

The literature was again evaluated in July 2002 for studies published since the 1997 TEC Assessment. For the diagnosis of neurocardiogenic syncope, no studies were found that would change the conclusions of the previous Assessment. The European Society of Cardiology guidelines find other indications for which tilt-table testing is not indicated—to assess response to treatment, after a single episode of syncope without injury, and when the clinical features have clear-cut vasovagal features. They state that tilt-table testing is less well established or there is divergent opinion when it is proposed to differentiate syncope from epilepsy, to evaluate patients with unexplained falls, or to evaluate pre-syncope or dizziness.

However, since the 1997 TEC Assessment, two 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 bradycardiac 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, was 85.4 %.(6)

In another study of pacemakers by Sutton and co-workers, 42 patients were randomized to receive pacemaker or no pacemaker. (7)  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 and severity of neurogenic syncope, and who are refractory to treatment merit consideration for pacemaker therapy, tilt-table testing to evaluate cardioinhibitory response may be considered medically necessary.

2010 Update

A search of peer reviewed literature through June 2010 identified no new clinical trial publications or any additional information. In addition, the studies that have been identified do not differentiate tilt table testing for high-risk vs. non-high-risk patients.

2013 Update

A search of peer reviewed literature was conducted through January 2013. Other than what is addressed below, no additional scientific information or publications were found that would alter the current coverage position of this medical policy.

Chronic Fatigue Syndrome

There is inadequate evidence of the effectiveness of tilt-table testing for identifying chronic fatigue syndrome (CFS) patients who would respond to medications to increase their blood pressure. Several case series have shown that patients with known CFS frequently have abnormal responses to tilt-table testing, and CFS patients in these series frequently appear to respond to anti-hypotensive medications commonly used in patients with neurally mediated hypotension. These case studies fail to demonstrate, however, any value of tilt-table testing in distinguishing CFS patients that would respond to these medications from those who would not.

ICD-9 Codes
89.59, 337.00, 337.01, 337.09, 413.9, 426.0, 426.10, 426.11, 426.12, 426.13, 426.82, 426.89, 426.9, 427.89, 458.0, 780.39, 780.2, 780.4, 992.1, V15.88, V45.01, V81.2
ICD-10 Codes

G90.09, G90.01, G90.09, I20.8, I44.2, I44.30, I44.0, I44.1, I44.1, I45.81, I45.89, I45.9, I49.8, R00.1, I95.1, R56.9, R55, R42, T67.1XXA, Z91.81, Z95.0, Z13.6, 4A02X9Z

Procedural Codes: 93660
References
  1. Tilt-Table Testing for Evaluation of Syncope. Chicago, Illinois:  Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1995 June) 10(15): 1-20.
  2. Benditt, D.G., Petersen, M., et al. Cardiac pacing for prevention of recurrent vasovagal syncope. Annals of Internal Medicine (1995) 122(3):204-9.
  3. Benditt, D.G., Ferguson, D.W., et al. Tilt table testing for assessing syncope. American College of Cardiology. Journal of the American College of Cardiology (1996) 28(1):263-75.
  4. Tilt-Table Testing for Evaluation of Syncope. Chicago, Illinois:  Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1997 June) 12(7):1-37.
  5. Linzer, M., Yang, E.H., et al. Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy Assessment Project of the American College of Physicians. Annals of Internal Medicine (1997) 127(1):76-86.
  6. Connolly, S.J., Sheldon, R., et al. The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. Journal of the American College of Cardiology (1999) 33(1):16-20.
  7. Sutton, R., Brignole, M., et al. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope: pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators. Circulation (2000) 102(3):294-9.
  8. Brignole, M., Alboni, P., et al. Guidelines on management (diagnosis and treatment) of syncope. European Heart Journal (2001) 22(15):1256-306.
  9. Klonoff D. Chronic fatigue syndrome and neurally mediated hypotension. JAMA. 1996; 275(5):359-360.
  10. Tilt Table. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2010 October - Archived) Medicine 2.01.09.
History
June 2013  New 2013 BCBSMT medical policy.
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Tilt Table Testing