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Coverage criteria policies

Cardiac event monitoring

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for:

  1. Mobile cardiovascular telemetry (MCT),
  2. Implantable cardiac loop recorders.

Prior authorization is not required for the following external unattended cardiac monitoring devices:

  1. Holter monitors,
  2. Ambulatory event monitors (AEM), the new generations of FDA-approved ambulatory event monitors such as the iRhythm Zio® Patch and the CardioNet CardioKey cardiac event recorder.

Coverage

Indications that are covered for mobile cardiac outpatient telemetry (MCOT)

MCOT is covered if all of the following criteria are met:

  1. Must be ordered by a cardiologist; and
  2. Suspected cardiac arrhythmia not detected with standard Holter monitor or ambulatory event monitoring.  Standard monitoring must have been performed within the past 90 days / during this episode of care. Summary report must be submitted with the prior authorization. or
  3. Symptoms occur infrequently such that the arrhythmia is unlikely to be diagnosed by Holter (in a 48 hour period) or ambulatory event monitoring; and
  4. One of the following is present:
    1. Unexplained syncope, pre-syncope and / or palpitation;
    2. Assessment of asymptomatic or symptomatic arrhythmia in patients who are status-post electrophysiology ablation procedure;
    3. To monitor patient’s response to medication prescribed to treat an arrhythmia;
    4. History of heart transplantation.
    5. For evaluation of members with suspected atrial fibrillation as a cause of cryptogenic stroke.

Indications that are covered for implantable cardiac loop recorders (ICR)

  1. ICR is covered for evaluation of symptoms such as syncope, dizziness, or similar symptoms when all of the following criteria have been met:
    1. ICR must be ordered by a cardiologist, and
    2. A cardiac arrhythmia is suspected as a cause of the symptoms; and
    3. Suspected cardiac arrhythmia is not detected with standard 30 day cardiac monitoring (non-implantable ambulatory event monitoring or mobile cardiac outpatient telemetry). Standard monitoring must have been performed within the past 90 days / during this episode of care.
  2. ICR is covered for cryptogenic stroke with suspected occult atrial fibrillation as the cause of the stroke when all of the following criteria have been met;
    1. ICR must be ordered by a cardiologist, and
    2. Suspected cardiac arrhythmia is not detected with standard cardiac monitoring for 30 days (non-implantable ambulatory event monitoring or mobile cardiac outpatient telemetry). Standard monitoring must have been performed within the past 90 days / during this episode of care.

Indications that are not covered

  1. LifeWatch LifeStar ACT Ex service because there is no evidence that reflex testing sequences have better outcomes than standard testing.
  2. Mobile phone “apps” that monitor heart rhythm are considered investigational because there is insufficient scientific evidence to prove their clinical value.

Definitions

Cryptogenic stroke is defined as a brain infarction not clearly attributable to a definite cause or origin.

Holter monitor (also known as continuous external unattended cardiac monitoring device). Provides a continuous record of the electrocardiogram for up to 48 hours (some models allow up to 72 hours).

Ambulatory event monitor (AEM, also known as loop recorder) is worn for 20-30 days. These devices may have memory loop recording, auto-triggering and/or patient triggering features.

Next Generation Holter Monitors / ambulatory event monitors, such as:
  • iRhythm Zio® Patch is an externalized, single-use monitor. Unlike Holter monitors, this device can be worn during showering and daily activities and remain on the patient for more than 48 hours and up to 14 days.
  • CardioNet CardioKey is a long-term cardiac rhythm monitor that provides continuous monitoring for up-to-14 days.

Mobile cardiac outpatient telemetry (MCOT), (also known as real-time continuous attended cardiac monitoring systems) are offered by a variety of companies: - CardioNet Mobile Cardiac Outpatient Telemetry (MCOT) Service; Cardiac Telecom and Health Monitoring Services of America’s Telemetry @ Home Service; and LifeWatch LifeStar ACT (Ambulatory Cardiac Telemetry), this type of device is similar to an AEM, with one important difference. The device is completely automatic and requires no patient intervention to either capture or transmits electrocardiographic data. These systems typically use some sort of wireless technology (such as cellular phone networks) to transmit the data to the company’s central monitoring facility, where the electrocardiogram is analyzed in real-time. The patient's physician is notified of potentially significant electrocardiographic events based upon criteria prescribed by the physician. Such notification is done daily of even more frequently, and may be delivered by email of fax. Like an AEM, the duration of an MCOT study is typically up to 30 days.

Occult atrial fibrillation refers to atrial fibrillation occurring without any readily discernible signs or symptoms. Occult is used in this context to mean “hidden.”

Implantable cardiac loop recorder (ILR) – Cardiac implantable loop recorders (ILRs) assess arrhythmias in symptomatic and asymptomatic patients. The device is implanted subcutaneously in the left side of the chest. Such a device provides constant surveillance and both retrospective and prospective ECG data, and may be left in place for up to 3 years.

LifeWatch LifeStar ACT Ex service uses the technology of a 3-channel ambulatory cardiac telemetry platform and remote retrieval of digital Holter data to provide arrhythmia diagnosis. This two part service begins as a 24-48 hour Holter Analysis, and if the Holter is negative, the ACT 3-channel real-time telemetry starts for up to 30 days.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

MCT codes – require prior authorization

93228

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report

93229

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

Codes

Implantable Loop Recorder codes – require prior authorization

33282

Implantation of patient-activated cardiac event recorder

C1764

Event recorder, cardiac (implantable)

Codes

AEM codes – No prior authorization

93268

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation

93270

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection)

93271

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; transmission download and analysis

93272

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; physician review and interpretation

0295T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation.

0296T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation

0297T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report.

0298T

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation

Codes

Holter monitor codes – No prior authorization

93224

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation

93225

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)

93226

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report

93227

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; physician review and interpretation

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Afazl, M. R., Gunda, S., Waheed, S., Sehar, N., Maybrook, R. J., Dawn, B., & Lakkireddy, D. (2015). Role of outpatient cardiac rhythm monitoring in Cryptogenic stroke: A systematic review and Meta-Analysis. Pacing and Clinical Electrophysiology, 38(10), 1236–1245. doi:10.1111/pace.12688.
  2. Benditt, D. Syncope in adults: Clinical manifestations and diagnostic evaluation. In: UpToDate, Kowey, P. and Hockberger, RS (Eds), UpToDate, Waltham, MA. (Accessed on February 23, 2017.)
  3. Calkins H, Brugada J, Packer DL, et al. European Heart Rhythm Association (EHRA); European Cardiac Arrhythmia Society (ECAS); American College of Cardiology (ACC); American Heart Association (AHA); Society of Thoracic Surgeons (STS). HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2007;4(6):816-861.
  4. Caplan, LR. Overview of the evaluation of stroke. In: UpToDate, Kasner, SE (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017.)
  5. ECRI Institute. (2014). Mobile Cardiac Outpatient Telemetry for Detecting Arrhythmias. Plymouth Meeting, PA: ECRI Institute.
  6. Favilla, C. G., Ingala, E., Jara, J., Fessler, E., Cucchiara, B., Messé, S. R., ... & Kasner, S. E. (2015). Predictors of finding occult atrial fibrillation after cryptogenic stroke. Stroke, 46(5), 1210-1215.
  7. Gladstone, D. J., Spring, M., Dorian, P., Panzov, V., Thorpe, K. E., Hall, J., ... & Sharma, M. (2014). Atrial fibrillation in patients with cryptogenic stroke. New England Journal of Medicine, 370(26), 2467-2477.
  8. Hayes, Inc. Hayes Health Technology Brief. Implantable Cardiac Loop Recorders for Detection of Atrial Fibrillation Following Cryptogenic Stroke. Lansdale, PA: Hayes, Inc.; February, 2015. Reviewed January, 2017.
  9. Hayes, Inc. Hayes Health Technology Brief. Mobile Cardiac Outpatient Telemetry (MCOT) (CardioNet Ambulatory ECG Monitor; CardioNet Inc.) for Home Monitoring of Cardiac Patients.. Lansdale, PA: Hayes, Inc.; September, 2011. Reviewed October, 2013;Archived October, 2014.
  10. Hayes, Inc. Hayes Health Technology Brief. Zio Patch (iRhythm Technologies Inc.) Long-Term Ambulatory Cardiac Rhythm Monitoring. Lansdale, PA: Hayes, Inc.; November, 2015. Reviewed October, 2016.
  11. Hayes, Inc. Hayes Medical Technology Directory Report. Implantable Cardiac Loop Recorders for Diagnosis and Management of Syncope in Adults. Lansdale, PA: Hayes, Inc.; March, 2016.
  12. Podrid, PJ. Ambulatory ECG monitoring. In: UpToDate, Zimetbaum, PJ (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017.)
  13. Rothman, S. A., Laughlin, J. C., Seltzer, J., Walia, J. S., Baman, R. I., Siouffi, S. Y., ... & Kowey, P. R. (2007). The diagnosis of cardiac arrhythmias: a prospective multi‐center randomized study comparing mobile cardiac outpatient telemetry versus standard loop event monitoring. Journal of cardiovascular electrophysiology, 18(3), 241-247.
  14. Sanna, T., Diener, H. C., Passman, R. S., Di Lazzaro, V., Bernstein, R. A., Morillo, C. A., ... & Lindborg, K. (2014). Cryptogenic stroke and underlying atrial fibrillation. New England Journal of Medicine, 370(26), 2478-2486.
  15. Sposato, L. A., Cipriano, L. E., Saposnik, G., Vargas, E. R., Riccio, P. M., & Hachinski, V. (2015). Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. The Lancet Neurology, 14(4), 377-387.
  16. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACC scientific statement on the evaluation of syncope. Circulation. 2006;113:316‐327.
  17. Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Associa_on (EHRA); Heart Failure Associa_on (HFA); Heart Rhythm Society (HRS), Moya A, Su_on R, Ammira_ F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30(21):2631‐2671.

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Policy activity

  • 03/25/2010 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 03/2017
Revision date
  • 04/21/2017

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