Program Operations Manual System (POMS)
TN 31 (08-20)
COMPASSIONATE ALLOWANCES INFORMATION
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EISENMENGER SYNDROME
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ALTERNATE NAMES
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Eisenmenger Complex; Eisenmenger Disease; Eisenmenger Reaction; Eisenmenger Physiology;
Congenital heart defect – Eisenmenger; Cyanotic Heart Disease –Eisenmenger; Birth
Defect heart – Eisenmenger; ES
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DESCRIPTION
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Eisenmenger syndrome is a rare progressive heart condition that results from uncorrected congenital (present
at birth) heart disease. Babies born with this condition have abnormal communication
between the normal pumping chambers of the heart. This communication allows blood
that has already received oxygen from the lungs to flow back through the lungs, instead
of being circulated to the rest of the body. This abnormal blood flow through the
lungs, results in higher pressure within the pulmonary circulation damaging these
vessels and causing pulmonary hypertension. As this condition worsens and the pressure
increases, the backed up oxygen poor blood is then circulated to the rest of the body.
Eisenmenger syndrome usually develops before a child reaches puberty, but may develop
in adolescence and early adulthood.
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DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND
ICD-9-CM/ICD-10-CM
CODING
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Diagnostic testing: Diagnostic testing for Eisenmenger syndrome includes:
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Complete blood count (CBC);
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Physical findings:
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Abnormal heart rhythm (arrhythmia);
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Bluish lips, fingers, toes, and skin (cyanosis);
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Heart murmurs (extra sounds when listening to the heart);
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Episodes of coughing up blood;
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Enlarged fingers and toes (clubbing).
ICD-9: 745.4
ICD-10: Q24.9
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TREATMENT
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Treatment is aimed at controlling the child’s symptoms, improving quality of life,
and the prevention of serious complications.
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PROGRESSION
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Generally, the presence of Eisenmenger syndrome signals inoperability of the underlying
congenital problem. Some children may benefit from heart and lung transplantation
or lung transplant.
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SUGGESTED PROGRAMMATIC
ASSESSMENT* |
Suggested MER for Evaluation:
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Clinical history and examination that describes the diagnostic features of the impairment;
and
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Laboratory studies are needed to confirm the diagnosis.
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Suggested Listings for Evaluation:
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DETERMINATION |
LISTING
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REMARKS |
Meets |
4.06 |
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104.06
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Equals |
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* Adjudicators may, at their discretion, use the Medical Evidence of Record or the
listings suggested to evaluate the claim. However, the decision to allow or deny the
claim rests with the adjudicator.
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