TL;DR: Aetna, a CVS Health company, modified CPB 0008 governing color-flow Doppler echocardiography and myocardial strain imaging in adults, effective September 26, 2025. Here's what changes for billing teams.
This update to the Aetna color-flow Doppler echocardiography coverage policy affects billing for CPT +93325 (color-flow velocity mapping) and CPT 93356 (myocardial strain imaging). The policy defines 20 covered indications for +93325 and adds structured criteria for when 93356 is medically necessary—including specific cardiotoxic chemotherapy monitoring scenarios. If your practice bills cardiac ultrasound for Aetna members, audit your documentation before September 26, 2025.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna (Aetna, a CVS Health company) |
| Policy | Color-Flow Doppler Echocardiography in Adults |
| Policy Code | CPB 0008 Aetna |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Cardiology, Oncology (cardio-oncology), Cardiac Surgery, Electrophysiology |
| Key Action | Audit documentation for CPT +93325 and CPT 93356 against the updated indication list before September 26, 2025 |
Aetna Color-Flow Doppler Echocardiography Coverage Criteria and Medical Necessity Requirements 2025
CPB 0008 covers two distinct services under this Aetna echocardiography coverage policy: color-flow Doppler mapping (CPT +93325) and myocardial strain imaging (CPT 93356). They have separate medical necessity criteria. Don't conflate them when building your documentation workflows.
Color-Flow Doppler — CPT +93325
Aetna considers CPT +93325 medically necessary for 20 specific indications. These range from common presentations like congestive heart failure, dyspnea, and atrial fibrillation/flutter to more specific scenarios like intraoperative use during excision of a left atrial mass and monitoring after repair of tetralogy of Fallot.
Remember: +93325 is an add-on code. You cannot bill it alone. It must be billed alongside a primary echocardiographic imaging code—93306, 93308, 93312, 93350, or another applicable parent code from the policy. If you submit +93325 without a valid parent code, expect a claim denial.
The full 20 covered indications include evaluation of angina, aortic diseases, aortocoronary bypass grafts, cardiac tamponade, cardiomyopathy (including hypertrophic cardiomyopathy), heart murmurs, pericardial effusion, prosthetic valves, pulmonary hypertension, septal defects, left-to-right or right-to-left shunts, and valvular diseases including mitral regurgitation. Monitoring indications include post-tetralogy of Fallot repair, cardiotoxic chemotherapy monitoring, and status post ventricular tachycardia. This is a broad list—but Aetna will still deny claims where the diagnosis code doesn't map clearly to one of these categories.
Myocardial Strain Imaging — CPT 93356
This is where the policy gets more nuanced. CPT 93356 uses speckle tracking-derived assessment of myocardial mechanics. Aetna covers it in two scenarios, and the documentation requirements are tight.
Scenario 1: Left Ventricular Hypertrophy (LVH) with unclear etiology. Aetna considers 93356 medically necessary as an add-on to the primary echocardiogram when both of these are documented: (1) the etiology of LVH is unclear, and (2) there is clinical concern for infiltrative cardiomyopathy. Both conditions must be present. One alone doesn't meet medical necessity under this coverage policy.
Scenario 2: Cardiotoxic therapy monitoring. Aetna covers 93356 as an add-on to a primary echo in five sub-scenarios for patients on cardiotoxic agents or radiation. These are:
| # | Covered Indication |
|---|---|
| 1 | Initial evaluation before starting cardiotoxic medications or cardiotoxic radiation |
| 2 | Re-evaluation if a prior echocardiogram shows a new abnormality |
| 3 | Re-evaluation if the patient develops worsening symptoms during therapy |
| 4 | Initial post-treatment evaluation, conducted 3–12 months after completing treatment |
| 5 | Periodic surveillance for medium- and high-risk survivors |
The 3–12 month post-treatment window for the initial post-treatment evaluation matters. If you're billing 93356 at the 24-month mark as the "first" post-treatment evaluation, you're outside the covered window. Document when treatment ended.
Prior authorization requirements for these codes aren't spelled out explicitly in CPB 0008's clinical criteria section—but Aetna's prior auth requirements vary by plan and market. If your patients are on Medicare Advantage Aetna plans or employer-sponsored Aetna plans, verify prior auth requirements separately before billing 93356. Don't assume medical necessity criteria alone are sufficient.
Aetna Color-Flow Doppler Echocardiography Exclusions and Non-Covered Indications
CPB 0008 doesn't include a lengthy experimental/investigational list for these services. However, HCPCS C1886 (catheter, extravascular tissue ablation, any modality, insertable) appears in the related codes as "experimental and investigational." This code is in the policy's orbit but is not covered.
The real coverage risk here isn't an explicit exclusion list—it's failing to document the specific indication. Aetna won't deny +93325 because the procedure is experimental. They'll deny it because your documentation says "chest pain" when it should say "evaluation of angina" or because your ICD-10 doesn't map to one of the 20 covered indications. The same logic applies to 93356 for LVH cases where you can't demonstrate both unclear etiology and concern for infiltrative cardiomyopathy.
Coverage Indications at a Glance
Color-Flow Doppler Echocardiography — CPT +93325
| Indication | Status | Notes |
|---|---|---|
| During excision of left atrial mass | Covered | Intraoperative use; pair with C38.0 or D15.1 |
| Evaluation of angina | Covered | |
| Evaluation of aortic diseases | Covered | |
| Evaluation of aortocoronary bypass grafts | Covered | |
| Evaluation of atrial fibrillation/flutter | Covered | |
| Evaluation of cardiac function after Fontan procedure | Covered | Related CPT: 33617 |
| Evaluation of cardiac tamponade | Covered | |
| Evaluation of cardiomyopathy (including hypertrophic) | Covered | |
| Evaluation of congestive heart failure | Covered | |
| Evaluation of dyspnea | Covered | |
| Evaluation of heart murmur | Covered | |
| Evaluation of pericardial effusion | Covered | |
| Evaluation of prosthetic valves | Covered | |
| Evaluation of pulmonary hypertension | Covered | |
| Evaluation of septal defects | Covered | Related CPT: 33615 |
| Evaluation of left-to-right or right-to-left shunts | Covered | |
| Evaluation of valvular diseases (including mitral regurgitation, valve stenosis) | Covered | |
| Monitoring after repair of tetralogy of Fallot | Covered | |
| Monitoring during cardiotoxic chemotherapy | Covered | See 93356 criteria for strain imaging add-on |
| Status post ventricular tachycardia | Covered |
Myocardial Strain Imaging — CPT 93356
| Indication | Status | Documentation Required | Notes |
|---|---|---|---|
| Initial LVH evaluation with unclear etiology + concern for infiltrative cardiomyopathy | Covered | Both conditions must be documented | Add-on to primary echo only |
| Initial evaluation before cardiotoxic therapy (medications) | Covered | Document start of therapy | Add-on to primary echo only |
| Initial evaluation before cardiotoxic radiation | Covered | Document start of therapy | Add-on to primary echo only |
| Re-evaluation if echo shows new abnormality during therapy | Covered | Reference the abnormal echo in documentation | Add-on to primary echo only |
| Re-evaluation with worsening symptoms during therapy | Covered | Document symptom change | Add-on to primary echo only |
| Initial post-treatment evaluation | Covered | Must occur 3–12 months after treatment completion | Bill outside this window = likely denial |
| Periodic surveillance for medium/high-risk survivors | Covered | Risk stratification must be documented |
Aetna Color-Flow Doppler Echocardiography Billing Guidelines and Action Items 2025
These are the steps your billing team needs to take before the September 26, 2025 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your +93325 claims for proper parent code pairing. Pull your last 90 days of +93325 claims. Confirm every one has a valid parent echocardiography code (93306, 93308, 93312, 93314, 93350, 93351, or equivalent). Any claim with +93325 as the sole line item will deny. |
| 2 | Map your +93325 ICD-10 codes to the 20 covered indications. Build or update a crosswalk in your charge capture system. For example, atrial fibrillation maps cleanly. But "chest pain unspecified" doesn't map to any indication—recode or get better documentation before billing. |
| 3 | Tighten your 93356 documentation templates for LVH cases. The coverage policy requires both unclear etiology and concern for infiltrative cardiomyopathy. Your ordering physician's note needs to state both, explicitly. A note that says "LVH, cause unknown" is not enough. Add a structured field to your order intake or template. |
| 4 | Create a cardiotoxic therapy tracking workflow for 93356. For each oncology patient receiving cardiotoxic agents or radiation, document the treatment start date, current phase (pre-treatment, active treatment, post-treatment), and any new echo findings or symptom changes. Your coders need this data to assign 93356 correctly. The 3–12 month post-treatment window is a hard boundary—build a flag into your scheduling system. |
| 5 | Verify prior authorization requirements at the plan level before billing 93356. Aetna's prior auth rules vary by market and product type. Don't assume that meeting CPB 0008's medical necessity criteria means you're clear to bill. Check the member's specific plan. Talk to your compliance officer if you're uncertain how this applies to your Aetna patient mix—especially for Medicare Advantage or ASO plans with custom benefit designs. |
| 6 | Update your denial tracking to flag CPB 0008. Set up a worklist for any denial citing CPB 0008 after September 26, 2025. If you see a spike in +93325 or 93356 denials post-effective date, you need to identify the pattern fast—documentation gap, code pairing error, or indication mismatch. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Color-Flow Doppler Echocardiography Under CPB 0008
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| +93325 | CPT (add-on) | Doppler echocardiography color flow velocity mapping — list separately in addition to codes for echocardiographic imaging |
| 93356 | CPT (add-on) | Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics — list separately in addition to primary echocardiogram |
Parent CPT Codes for +93325 and 93356 (Related Codes — Required for Billing Add-Ons)
| Code | Type | Description |
|---|---|---|
| 93306 | CPT | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, with spectral Doppler echocardiography, and with color flow Doppler echocardiography; complete |
| 93307 | CPT | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording; complete, without spectral or color Doppler echocardiography |
| 93308 | CPT | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording; follow-up or limited study |
| 93312 | CPT | Echocardiography, transesophageal, real time with image documentation (2D), with or without M-mode recording; including probe placement, image acquisition, interpretation and report |
| 93314 | CPT | Echocardiography, transesophageal; image acquisition, interpretation and report only |
| 93315 | CPT | Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report |
| 93317 | CPT | Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only |
| 93303 | CPT | Transthoracic echocardiography for congenital cardiac anomalies; complete |
| 93304 | CPT | Transthoracic echocardiography for congenital cardiac anomalies; follow-up or repeat study |
| 93350 | CPT | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, during rest and cardiovascular stress test |
| 93351 | CPT | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, during rest and cardiovascular stress test; including performance of continuous electrocardiographic monitoring, with physician supervision |
| +93320 | CPT (add-on) | Doppler echocardiography, pulsed wave and/or continuous wave with spectral display — list separately in addition to codes for echocardiographic imaging |
| +93321 | CPT (add-on) | Doppler echocardiography, pulsed wave and/or continuous wave; follow-up or limited study — list separately in addition to codes for echocardiographic imaging |
| 76825 | CPT | Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; complete |
| 76826 | CPT | Echocardiography, fetal, cardiovascular system; follow-up or repeat study |
| 76827 | CPT | Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete |
| 76828 | CPT | Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study |
| 75561 | CPT | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences |
| 33615 | CPT | Repair of complex cardiac anomalies (e.g., tricuspid atresia) by closure of atrial septal defect and anastomosis of right atrium with pulmonary artery |
| 33617 | CPT | Repair of complex cardiac anomalies (e.g., single ventricle) by modified Fontan procedure |
| 93650 | CPT | Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block |
| 93653 | CPT | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording |
| 93654 | CPT | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right ventricular pacing and recording |
Not Covered / Experimental HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| C1886 | HCPCS | Catheter, extravascular tissue ablation, any modality (insertable) | Experimental and investigational per CPB 0008 |
Key ICD-10-CM Diagnosis Codes
This policy maps to 569 ICD-10-CM codes. Below are the most clinically relevant codes for color-flow Doppler echocardiography billing. Review the full list at the Aetna CPB 0008 policy source.
| Code | Description |
|---|---|
| C38.0 | Malignant neoplasm of heart (left atrial mass) |
| C00.0–C96.Z | Malignant neoplasms (cardiotoxic chemotherapy monitoring) |
| D15.1 | Benign neoplasm of heart (left atrial mass) |
| I05.0–I05.9 | Diseases of mitral valve |
| I06.0–I06.9 | Diseases of aortic valve |
| I07.0–I07.3 | Rheumatic tricuspid valve diseases |
| I01.1 | Acute rheumatic endocarditis |
| I01.2 | Acute rheumatic myocarditis |
| I01.8 | Other acute rheumatic heart disease |
| I01.9 | Acute rheumatic heart disease, unspecified |
| I02.0 | Rheumatic chorea with heart involvement |
| A40.0–A40.9 | Streptococcal sepsis (endocarditis/pericarditis evaluation) |
| A41.1–A41.53 | Other sepsis diagnoses (Staphylococcus aureus, gram-negative, E. coli, Pseudomonas, Serratia) |
| A52.03 | Syphilitic endocarditis |
| A54.83 | Gonococcal heart infection |
| B39.4 (with I32) | Histoplasmosis capsulati — pericarditis |
| B39.4 (with I39) | Histoplasmosis capsulati — endocarditis |
Billing note: For B39.4, Aetna specifies you must bill this code alongside either I32 (for pericarditis) or I39 (for endocarditis). Submitting B39.4 alone will not support coverage.
Get the Full Picture for CPT 93356
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.