Transthoracic Echocardiograpy Program for Horizon BCBS to Begin July 1, 2009

Frequently Asked Questions Regarding the Horizon Cardiology Program

Q: What members are covered under this program?
A: Horizon Commercial (Fully Insured/ASO), SHBP, and Medicare.

Q: What new cardiology imaging modalities fall under this program effective July 1, 2009?
A: Outpatient, non-emergent transthoracic echocardiography (TTE).

Q: What are the CPT codes that require prior authorization under the Horizon Cardiology Program?
A: Nuclear stress testing: 78460, 78461, 78464, 78465
    Cardiac CT: 0145T, 0146T, 0148T, 0150T
    Cardiac PET: 78459, 78491, 78492
    Cardiac MRI: 75557, 75558, 75559, 75560, 75561, 75562, 75563, 75564
    Stress echo: 93350, 93351
    Diagnostic left heart catheterization: 93510, 93511
    Transthoracic echocardiography*: 93303, 93304, 93306, 93307, 93308
    *effective July 1, 2009

Q: What are the CareCore National phone and fax numbers for the Horizon Cardiology Program?
A: Medical necessity reviews can be initiated by phone (866-496-6200), fax (888-785-2480) or web at www.carecorenational.com.

Q: Are transesophageal echocardiography (TEE) included on the prior authorization list for the Horizon Cardiology Program effective July 1, 2009?
A: No.

Q: Are pediatric cardiologists required to obtain a prior authorization for the Horizon Cardiology Program?
A: While pediatric cardiologists do not require medical necessity reviews, all requests for the above CPT codes require an authorization number. To obtain an authorization number for the above CPT codes, the exams must be registered through CareCore National. The authorization number is required for claims processing and payment. The registration requests can be submitted by phone, fax or web as described above.

Q: What is the process for obtaining an authorization number for TTE exams?
A: All outpatient TTE requests (outpatient hospital, free standing facility, or office) require a registration process prior to the performance of the study to insure reimbursement. Authorization numbers can be obtained by fax or phone (see above) or by web at www.carecorenational.com.

Q: Do all TTE requests require a medical necessity determination?
A: No, medical necessity determinations for TTE are not required for any member that has no prior TTE on record at CareCore National. At the time of TTE registration, if no prior TTE is on record at CareCore National, an authorization number will be provided immediately after member demographic information, CPT code, and ICD-9 codes are provided.

Q: How is a medical necessity review performed by CareCore National?
A: Once the TTE request is registered, a medical necessity determination will be initiated immediately if a prior TTE is on record as having been performed on this member. This medical necessity determination is a limited series of questions that will be asked by CareCore National’s cardiology nursing staff or through a web-based questionnaire. If at the conclusion of this brief review, the request meets criteria for medical necessity, an authorization number will be issued immediately. If faxed information is required, the case will be place in a hold status pending receipt of the requested information. Once all requested information is received and medical necessity has not been demonstrated, the requested is forward to a cardiologist to review for a final medical necessity determination.

Q: How does CareCore National determine that a given member had a prior TTE performed?
A: CareCore National has obtained claims data from Horizon BCBS dating back one year from the institution of this program for the primary TTE CPT codes including: 93303, 93304, 93306, 93307, and 93308. These claim records are stored in CareCore National’s data files and are used during the registration process.

Q: What percentage of TTE requests will be approved by the registration only process and what percentage require medical necessity review?
A: CareCore National's past experience with TTE reviews demonstrated that during the first year of the program, 75% of all TTE requests are approved by a registration only process; 25% of the requests went to a medical necessity determination.

Q: What criteria does CareCore National use in making medical necessity determinations for TTE?
A: The CareCore National criteria for TTE were created by a panel of practicing academic and clinical cardiologists using the 2003 Guideline Update for the Clinical Use of Echocardiography, ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease, and ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography.