Pending Policies - Medicine
Tilt Table Testing
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Tilt-table testing may be considered 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
o There is no evidence of structural cardiovascular disease (based on thorough history and physical, 12-lead ECG, echocardiogram and formal exercise testing); OR
o 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; OR
• Differentiating convulsive (seizure-like movement) syncope, from true seizure activity.
Tilt-table testing is considered experimental, investigational and/or unproven for all other indications including, but not limited to:
• Assessing recurrent dizziness or presyncope; OR
• Evaluating unexplained syncope in the setting of peripheral neuropathies or dysautonomias; OR
• Follow-up evaluations to assess therapy of neurally mediated syncope; OR
• 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; OR
• Identifying patients with chronic fatigue syndrome and/or evaluating treatment effectiveness of this condition.
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.
This policy was originally developed in 1993 and has been updated with searches of scientific literature through January 2018. The following is a summary of the key literature to date.
The tilt-table test for the diagnosis of syncope was based on a 1997 Blue Cross Blue Shield Association Technology Evaluation Center (TEC) Assessment (4). The TEC Assessment was based on a prior 1995 BCBSA TEC Assessment (1). 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.
However, since the 1997 BCBSA TEC Assessment, two randomized clinical trials (RCT) evaluating dual-chamber pacemakers as a treatment for neurocardiogenic syncope in patients with refractory syncope have been published. (6, 7) 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 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.
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.
In a 2018 DynaMed Plus article titled Vasovagal Syncope/Overview and Recommendations, it is recommended to consider tilt testing if the etiology is undetermined after initial evaluation or to confirm diagnosis in patients with suspected neurally mediated syncope. (11)
Professional Guidelines and Position Statements
Heart Rhythm Society
In the 2015 Heart Rhythm Society Expert Consensus Statement (12), the following recommendations were made about tilt table testing:
• Tilt-table testing can be useful for assessing patients with suspected vasovagal syncope who lack a confident diagnosis after the initial assessment.
• Tilt-table testing is a reasonable option for differentiating between convulsive syncope and epilepsy, for establishing a diagnosis of pseudosyncope, and for testing patients with suspected vasovagal syncope but without clear diagnostic features.
• Tilt-table testing may be considered to identify patients with a hypotensive response who would be less likely to respond to permanent cardiac pacing.
2017 Guideline for the American College of Cardiology, American Heart Association and the Heart Rhythm Society (ACC/AHA/HRS) for the Evaluation and Management of Patients with Syncope: (12)
Executive summary recommendations specific to tilt table testing:
• If the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with suspected vasovagal syncope (VVS)
• Tilt-table testing can be useful for patients with syncope and suspected delayed orthostatic hypotension (OH) when initial evaluation is not diagnostic.
• Tilt-table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients.
• Tilt-table testing is reasonable to establish a diagnosis of pseudosyncope.
• Tilt-table testing can be useful for pediatric patients with suspected VVS when the diagnosis is unclear.
• Tilt-table testing is not recommended to predict a response to medical treatments for VVS.
European Society of Cardiology (ESC) (13)
Task Force for the Diagnosis and Management of Syncope: ESC guidelines for the management of syncope, updated in 2009, include recommendations for tilt table testing. The guideline states that in most studies, the main indication for tilt testing has been to confirm a diagnosis of reflex syncope in patients in whom this diagnosis is suspected but not confirmed by initial evaluation. Tilt testing is usually not needed in patients whose reflex syncope is already diagnosed by clinical history, and in patients with single or rare syncope, unless special circumstances exist (e.g., injury, anxiety, occupational implications).
Indications and levels of evidence are classified in the ESC guideline as follows:
• Class I: Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.
• Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure
o IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
o IIb: Usefulness/efficacy is less well established by evidence/opinion.
• Class III: Evidence or general agreement that the given treatment or procedure is not useful/effective and in some cases, may be harmful
• Level of evidence A: Data derived from multiple randomized clinical trials or meta-analyses
• Level of evidence B: Data derived from a single randomized clinical trial or large non-randomized studies
• Level of evidence C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries.
The ESC guideline includes the following recommendations:
• Class I, level of evidence B: Tilt testing is indicated in the case of an unexplained single syncopal episode in high risk-settings (e.g., occurrence of or potential risk of physical injury or with occupational implications), or recurrent episodes in the absence of organic heart disease, or in the presence of organic heart disease, after cardiac causes of syncope have been excluded.
• Class I, level of evidence C: Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patient.
• Class IIa, level of evidence C: Tilt testing should be considered to discriminate between reflex and orthostatic hypotension.
• Class IIb, level of evidence C
o Tilt testing may be considered for differentiating syncope with jerking movements from epilepsy.
o Tilt testing may be indicated for evaluating patients with recurrent unexplained falls
o Tilt testing may be indicated for evaluating patients with frequent syncope and psychiatric disease
• Class III, level of evidence B: Tilt testing is not recommended for assessment of treatment.
• Class III, level of evidence C: Isoproterenol tilt testing is contraindicated in patients with ischemic heart disease.
Summary of Evidence
Although tilt table testing has not been evaluated in randomized controlled trials, it has become an established diagnostic tool in the evaluation of patients with syncope when the cause has not been established based on a detailed history and physical examination and routine diagnostic testing.
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The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
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. PMID: 7810939
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. PMID: 8752825
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. PMID: 9214258
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. PMID: 9935002
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. PMID: 10899092
8. Klonoff D. Chronic fatigue syndrome and neurally mediated hypotension. JAMA. 1996; 275(5):359-360. PMID: 8569010
9. Tilt Table-Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2010 October) Medicine 2.01.09.
10. Sheldon RS, Grubb BP 2nd, et al., 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal syncope. Heart Rhythm. 2015 Jun; 12(6): e41-63. PMID: 25980576
11. National Library of Medicine: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. 116865, Vasovagal syncope; [updated 2017 Apr 06]; Available at: <http://www.dynamed.com> (accessed Feb 22, 2018)
12. 2017 ACC/AHA/HRS Syncope Guideline: Executive Summary. Circulation. 2017; 136: e25–e59. DOI: 10.1161/CIR. PMID: 28280232
13. Moya A, Sutton R, Ammirati F, et al. Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009 Nov;30(21):2631-7. PMID: 19713422
|4/15/2018||Document updated with literature review. Coverage unchanged. References 11, 12 and 13 added.|
|4/15/2017||Reviewed. No changes|
|4/15/2016||Document updated with literature review. The following was added to the listing of medically necessary indications: Differentiating convulsive (seizure-like movement) syncope, from true seizure activity.|
|10/1/2015||Reviewed. No changes.|
|6/1/2014||Document updated with literature review. Coverage unchanged.|
|3/1/2013||Document updated with literature review. The following was added to the listing of experimental, investigational and unproven indications: “Identifying patients with chronic fatigue syndrome and/or evaluating treatment effectiveness of this condition.”|
|9/15/2010||Document updated with literature review. The following was changed: Tilt-table testing may be considered medically necessary when criteria are met, regardless of the number of syncopal episodes or the patient’s risk level. Also,|
|5/15/2008||Policy reviewed without literature review; new review date only.|
|12/1/2006||Revised/updated entire document|
|8/1/1999||Revised/updated entire document|
|6/1/1999||Revised/updated entire document|
|5/1/1996||Revised/updated entire document|
|7/1/1993||New medical document|
|Title:||Effective Date:||End Date:|
|Tilt Table Testing||04-15-2017||04-14-2018|
|Tilt Table Testing||04-15-2016||04-14-2017|
|Tilt Table Testing||10-01-2015||04-14-2016|
|Tilt Table Testing||06-01-2014||09-30-2015|
|Tilt Table Testing||03-01-2013||05-31-2014|
|Tilt Table Testing||09-15-2010||02-28-2013|
|Tilt Table Testing||05-15-2008||09-14-2010|
|Tilt Table Testing||12-01-2006||05-14-2008|