Latest Review Date:  November 2023

Category:  Medical

POLICY:

Acoustic cardiography and correlated audio-electric cardiography are considered not medically necessary for all indications.

DESCRIPTION OF PROCEDURE OR SERVICE:

Acoustic cardiography, or correlated audio-electric cardiography, describes the synchronization of EKG tracings with acoustic heart sounds and provides an assessment of the mechanical and electrical function of the heart via computer analysis.  There are several FDA approved devices for acoustic cardiography.

KEY POINTS:

A literature search was conducted through November 15, 2023.

Summary of Evidence

For individuals who have acoustic cardiography performed, the evidence consists of randomized controlled trials and prospective studies.  Relevant outcomes are overall survival, hospital admissions, and treatment related morbidity and mortality.  A number of published articles support that acoustic cardiography improves the detection of an S3 compared to auscultation alone. However, there is no evidence that acoustic cardiography contributes independent predictive information when combined with standard clinical workup for heart failure such as physical exam findings, laboratory testing, and routine imaging studies. When used to optimize CRT settings, several studies report that acoustic cardiography has a high correlation with Doppler echocardiography. No studies have demonstrated that acoustic cardiography is superior to echocardiography for this purpose. There is a lack of evidence for utilizing acoustic cardiography for detecting CAD.  The current studies are small and with potential bias. One study failed to show non-inferiority and other studies have been inconclusive. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

KEY WORDS:

Acoustic heart sound recording, correlated audioelectric cardiography, Audicor, Acarix, CADScor System

APPROVED BY GOVERNING BODIES:

Audicor (Inovise Medical, Inc) received 510(k) approval from the FDA on November 3, 2003 and was specifically for correlated audio-electric cardiography.  According to the FDA label, the intended use is as follows:  “The Audicor Upgrade System, when used with Audicor Sensors in the V3 and V4 positions on the chest wall, is intended for use in acquiring, analyzing and reporting ECG and heart sounds (phonocardiograph) data and to provide interpretation of the data for consideration by physicians.”  

Zargis Acoustic Cardioscan (ZAC) received 510k clearance in May 2004.  It is described as an electronic auscultatory device, intended to provide support to physicians in the evaluation of heart sounds in patients.  The product will acquire and record the acoustic signals of the heart and analyze these signals.  The analysis procedure will identify specific heart sounds that may be present.  Identified sounds include S1, S2, and suspected murmurs.  The device is indicated for use in a clinical setting, by a physician or by trained personnel who are acting on the orders of a licensed physician.  It is not intended as a sole means of diagnosis.  Interpretations of heart sounds offered by the Zargis Acoustic Cardioscan are only significant when used in conjunction with physician over-read as well as consideration of all other relevant patient data.  (FDA, Indications for Use).

CADence received 510k clearance in August 2017.  It is described as a “digital stethoscope used to record cardiac sounds, with integrated sensors used to record electrical activity of the heart (ECG)….”  The indications go on to state that, “The CADence system is not intended to be a stand-alone diagnostic device.  It does not supersede the judgment of the clinician.”

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING: 

CPT codes:

REFERENCES:

1. Arand P, Burton D, Myers R, et al.  Diagnostic performance of a computerized algorithm for augmenting the ECG with acoustical data. J Electrocardiol 2003; 36 Suppl: 169.
2. Azimpour F, Caldwell E, Tawfik P, et al. Audible Coronary Artery Stenosis. Am J Med. 2016 May;129 (5):515-521.
3. Bertini M, Delgado V, Bax JJ et al. Why, how and when do we need to optimize the setting of cardiac resynchronization therapy? Europace 2009; 11:v46-57.
4. Blue Cross Blue Shield Association. Correlated Audioelectric Cardiography.  Medical Policy Reference Manual, September 2008.
5. Chan W, Woldeyohannes M, Colman R et al. Haemodynamic and structural correlates of the first and second heart sounds in pulmonary arterial hypertension: an acoustic cardiography cohort study. BMJ Open 2013; 3(4).
6. Collins Sean P, Lindsell Christopher J, et al.  The effect of treatment on the presence of abnormal heart sounds in emergency department patients with heart failure.  American Journal of Emergency Medicine 2006; 24: 25-32.
7. Erne P. Beyond auscultation – acoustic cardiography in the diagnosis and assessment of cardiac disease. Swiss Med Wkly 2008; 138:439-52.
8. FDA. Audiocor System. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&productcode=DPS&knumber=&applicant=INOVISE%20MEDICAL%2C%20INC.
9. FDA. CADence System.  Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K170928
10. FDA. CADence System. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf17/K170928.pdf
11. FDA. Zargis Acoustic Cardioscan. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf3/K031517.pdf.
12. Hasan A, Abraham WT, Quinn-Tate L et al. Optimization of cardiac resynchronization devices using acoustic cardiography: a comparison to echocardiography. Congest Heart Fail, 2006; 12(suppl 1):25-31.
13. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
14. Kobza R, Roos M, Toggweiler S, et al.  Recorded heart sounds for identification of ventricular tachycardia.  Resuscitation, November 2008; 79(2): 265-272.
15. Kosmicki DL, Collins SP, Kontos MC et al. Noninvasive prediction of left ventricular systolic dysfunction in patients with clinically suspected heart failure using acoustic cardiography. Congest Heart Fail 2010; 16:249-53.
16. Maisel AS, Peacock WF, Shah KS et al. Acoustic cardiography S3 detection use in problematic subgroups and B-type natriuretic peptide “gray zone”: secondary results from the Heart failure and Audicor technology for Rapid Diagnosis and Initial Treatment Multinational Investigation. Am J Emerg Med July 12, 2010. [Epub ahead of print]
17. Michaels AD, Khan FU, Moyers B. Experienced clinicians improve detection of third and fourth heart sounds by viewing acoustic cardiography. Clin Cardiol 2010; 33:E36-E42.
18. Moyers B, Shapiro M, Marcus GM, et al.  Performance of phonoelectrocardiographic left ventricular systolic time intervals and B-type natriuretic peptide levels in the diagnosis of left ventricular dysfunction.  Ann Noninvasive Electrocardiol, April 2007; 12(2): 89-97.
19. Shitara J, Kasai T, Murata N, et al. Temporal changes of cardiac acoustic biomarkers and cardiac function in acute decompensated heart failure. ESC Heart Fail. 2021 Oct; 8(5): 4037-4347.
20. Taha N, Zhang J, Ranjan R et al. Biventricular pacemaker optimization guided by comprehensive echocardiography-preliminary observations regarding the effects on systolic and diastolic ventricular function and third heart sound. J Am Soc Echocardiogr 2010; 23:857-66.
21. Tavel Morton E and Katz Hart.  Usefulness of a new sound spectral averaging technique to distinguish an innocent systolic murmur from that of aortic stenosis.  American Journal of Cardiology, April 2005, Vol. 95, pp. 902-904.
22. Thomas JL, Ridner M, Cole JH, et al. The clinical evaluation of the CADence device in the acoustic detection of coronary artery disease. Int J Cardiovasc Imaging. 2018 Dec; 34(12):1841-1848.
23. Toggweiler S, Odermatt Y, Brauchlin A et al. The clinical value of echocardiography and acoustic cardiography to monitor patients undergoing anthracycline chemotherapy. Clin Cardiol 2013; 36(4):201-6.
24. Toggweiler S, Zuber M, Kobza R et al. Improved response to cardiac resynchronization therapy through optimization of atrioventricular and interventricular delays using acoustic cardiography: a pilot study. J Card Fail 2007; 13:637-42.
25. U.S. Food and Drug Administration (FDA).  Zargis Acoustic Cardioscan (ZAC).  510(k) Summary of Safety and Effectiveness.  www.fda.gov/cdrh/pdf6/K060197.pdf
26. Wang S, Fang F, Liu M et al. Rapid bedside identification of high-risk population in heart failure with reduced ejection fraction by acoustic cardiography. Int J Cardiol 2013; 168(3):1881-6.
27. Wang S, Lam YY, Liu M et al. Acoustic cardiography helps to identify heart failure and its phenotypes. Int J Cardiol 2012. [Epub ahead of print]
28. Wen YN, Lee APW, Fang F, et al. Beyaon auscultation: Acoustic cardiography in clinical practice. International Journal of Cardiology. 2014 April 1;172(3):548-560.
29. Wu X, Song L, Chen W, et al. Use of acoustic cardiography to assess left ventricular electromechanical synchronization during left bundle branch pacing. Heart Rhythm O2. 2023 Sep 11;4(10):632-640.
30. Yancy CW, Jessup M, Bozkurt B et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 128(16):e240-e327.
31. Zhang FW, Zhang YX, Si LY, et al. Value of acoustic cardiography in the clinical diagnosis of coronary heart disease. Clin Cardiol. 2021 Oct; 44(10): 1386-1392.
32. Zuber M, Erne P. Acoustic cardiography to improve detection of coronary artery disease with stress testing. World J Cardiol. 2010 May 26;2(5):118-24.
33. Zuber M, Toggweiler S, Quinn-Tate L et al. A comparison of acoustic cardiography and echocardiography for optimizing pacemaker settings in cardiac resynchronization therapy. Pacing Clin Electrophysiol 2008; 31:802-11.
34. Zuber M, Toggweiler S, Roos M et al. Comparison of different approaches for optimization of atrioventricular and interventricular delay in biventricular pacing. Europace, 2008; 10:367-73.

POLICY HISTORY:

Medical Policy Group, June 2004 (3)

Medical Policy Administration Committee, September 2004

Available for comment September 7-October 21, 2004

Medical Policy Group, June 2005 (1)

Medical Policy Group, June 2006 (1)

Medical Policy Group, June 2007 (1)

Medical Policy Group, June 2009 (1)

Medical Policy Group, June 2011 (3); Updated Description, Policy, Key Points, & References

Medical Policy Administration Committee, July 2011

Available for comment July 6 through August 22, 2011

Medical Policy Group, June 2012 (3); 2012 Updates to Key Points and References

Medical Policy Group, August 2013 (4): 2013 Updates. No changes.

Medical Policy Panel, June 2014 

Medical Policy Group, June 2014 (4): Updated Key Points and References. No changes to the policy statement at this time.  Policy inactive effective July 29, 2014.

Medical Policy Group, November 2015: 2016 Annual Coding Update. Moved cpt codes 0223T, 0224T, and 0225T to previous coding section.

Medical Policy Group, September 2019 (4):  Updates to Description, Key Points, Approved by Governing Bodies, References and Previous Coding.  Removed cpt codes 0068T – 0070T, deleted effective 1/2010.

Medical Policy Group, December 2020 (4): Updates to Description and Previous Coding.  Removed CPT codes 0223T-0225T, deleted effective 1/2016.  No change to policy statement.

Medical Policy Group, January 2022 (4): Reviewed by consensus. Updates to Description, Key Points, Approved by Governing Bodies, and References.  No new published peer-reviewed literature available that would alter the coverage statement in this policy.  Policy statement updated to remove “investigational”, no change to policy intent.

Medical Policy Group, June 2022:  Quarterly Coding Update.  Added CPT code 0716T to Current Coding and added Key Words Acarix, CADScr System.

Medical Policy Group, December 2022 (4): Reviewed by consensus.  No new published peer-reviewed literature available that would alter the coverage statement in this policy. 

Medical Policy Group, November 2023 (4): Updates to Key Points, Benefit Application, and References.  Added “for all indications” to policy statement for clarification.  No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.