Aetna considers cardiopulmonary exercise testing (CPET, CPT 94621) medically necessary for listed conditions after standard testing, including echocardiography, pulmonary function testing with diffusion capacity, and oxygen desaturation measured on the 6-minute walk test. The listed conditions include post-operative evaluation of chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy, developing exercise prescriptions for cardiac or pulmonary rehabilitation, evaluating exercise capacity and response to therapy in chronic heart failure patients considered for heart transplantation or other advanced therapies, and evaluating post-acute sequelae of COVID-19 (Long COVID). CPET is considered experimental, investigational or unproven as a screening exercise test, as a routine pre-operative assessment, and as a first-line diagnostic test for possible cardiac or pulmonary pathology.
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01Billing team: Bill CPT 94621 only for an indication in the policy's medically necessary list, and make sure the record shows the standard testing that comes first: echocardiography, pulmonary function testing with diffusion capacity, and oxygen desaturation measured on the 6-minute walk test.
02When CPET is used to tell cardiac limitation from pulmonary limitation, the record must show that standard testing such as echocardiography, electrocardiography and resting pulmonary function tests was inconclusive or non-diagnostic.
03Pair the claim with one of the ICD-10 diagnoses the policy lists as covered when criteria are met.
04Do not submit CPET as a covered service for screening exercise testing, routine pre-operative assessment, or first-line diagnostic testing of possible cardiac or pulmonary pathology, because the policy lists these as experimental, investigational or unproven.
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