Cardiac Monitors (ARCHIVED)

Policy ID: M-50-039

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: January 09, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective March 04, 2024. Click the Archive tab above for more information.

Policy ID: M-50-039

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: January 09, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Archived Date: March 04, 2024

Applies To: Commercial and Medicaid Expansion

Description

Ambulatory Cardiac Monitors:

Monitors activated only when triggered by the individual:

These monitors are often referred to as event monitors. The two (2) basic types are:
- Looping memory monitor : Activated by pushing a button; stores data from before and during symptom occurrence, prior to when it was activated; if activated immediately after a syncopal episode, it will record from the time before the event;
- Symptom event monitor : Activated by pushing a button; does not store data prior to when it was activated.

ZIO Patch:

An external monitor applied by adhesive to the chest; it records continuously and typically is worn up to 14 days. It is much less expensive than the mobile cardiac output telemetry and the implantable monitors.

Mobile Cardiac Outpatient Telemetry (MCOT):

A type of loop monitor that is auto-triggered by rhythm changes and also can be triggered by the individual. It is commonly ordered for 14 or 30 day periods.

Implantable Cardiac Monitor:

A monitor implanted under the skin that can monitor continuously and can be triggered by the individual; it may be implanted for several years.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Ambulatory Cardiac Monitors

The use of individual activated or auto activated external ambulatory event monitors or continuous ambulatory monitors that record and store information for periods greater than 48 hours may be considered medically necessary as a diagnostic alternative to Holter monitoring.

Quantity Level Limits (QLL)

Ambulatory event monitors may be considered medically necessary once in a 30 day period regardless of the number of events or recordings which occurred.
Ambulatory event monitors for greater than 30 consecutive days in a twelve (12) month period must be referred for a medical necessity determination. An additional 30 consecutive days may be considered medically necessary in EITHER of the following situations:
- After treatment has been initiated, the symptoms continue to occur; or
- No symptoms occurred during the initial 30 day use of the recorder.

Additional use greater than 30 consecutive days can be made only if documentation can establish the medical need for the frequency.

The use of individual activated or auto activated external ambulatory event monitors or continuous ambulatory monitors not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

93268

93270

93271

93272

Ambulatory Cardiac Monitoring (ZIO Patch) and Event Monitors

The use of long-term (greater than 48 hours) external ECG monitoring by continuous rhythm recording and storage (e.g., Zio Patch) may be considered medically necessary for EITHER one of the following:

Individuals who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope); or
Individuals with atrial fibrillation (AF) who have been treated with catheter ablation and in whom discontinuation of systemic anticoagulation is being considered.

The use of long-term (greater than 48 hours) external ECG monitoring by continuous rhythm recording and storage not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

93241

93242

93243

93244

93245

93246

93247

93248

Mobile Cardiac Outpatient Telemetry (MCOT)

MCOT is limited to a select population and may be considered medically necessary when ALL of the following are met:

The individual has failed a 48-hour Holter monitor and ONE of the following:
- A ZIO patch; or
- An individual-triggered event monitor; or
A Holter monitor has not been completed and the individual has failed ONE of the following:
- ZIO patch; or
- An individual-triggered event monitor.

Note: In all cases, the individual must meet the criteria as stated unless the individual's condition is such that a Holter monitor and an event monitor and a Zio Patch are not adequate to make a diagnosis. An explanation must be provided as to why only the MCOT would be sufficient.

Contraindications

Real-time outpatient cardiac monitoring is contraindicated for individuals at high risk of developing sustained ventricular tachycardia or ventricular fibrillation and/or would be more appropriately cared for in a hospital setting.
The MCOT is not indicated for individuals with mild to moderate symptoms of 'palpitations' or 'weakness.'
This system is also not indicated for use as a screening tool.

Use of cardiac surveillance and Holter or event monitoring for the same individual on the same day is considered not medically necessary.

The use of MCOT not meeting the criteria as indicated in this policy is considered not medical necessary.

QLL

MCOT is considered not medically necessary when more than one (1) monitoring episode is reported in a 30 day period.
MCOT is considered not medically necessary when more than two (2) monitoring episodes are reported in a (12) month period.

Procedure Codes

93228

93229

Implantable Cardiac Loop Recorder

The implantation and removal of a cardiac loop recorder may be considered medically necessary when the following criteria are met:

The individual has failed a 48-hour Holter monitor and ONE of the following:
- A ZIO patch; or
- An individual-triggered event monitor; or
A Holter monitor has not been completed and the individual has failed ONE of the following:
- A ZIO patch; or
- An individual-triggered event monitor.

Note: In all cases, the individual must meet the criteria as stated unless the individual's condition is such that a Holter monitor, and an event monitor and a Zio Patch are not adequate to make a diagnosis. An explanation must be provided as to why only the Implantable Cardiac Loop Recorder would be sufficient.

There is documentation of the following:

Palpitations; or
Dizziness; or
Syncope; or
Other transient symptoms which could be due to arrhythmia;or
Long term cardiac monitoring post cryptogenic stroke or transient ischemic attack (TIA); and
When BOTH of the following criteria are met:
- A cardiac arrhythmia is suspected as the cause of the symptoms; and
- EITHER of the following criteria are met:
  - Individuals with heart failure, prior MI or significant ECG abnormalities, noninvasive ambulatory monitoring, consisting of 30-day presymptom external loop recordings or MCOT, fails to establish a definitive diagnosis; or
  - Individuals without heart failure, prior MI or significant ECG abnormalities, symptoms occur so infrequently and unpredictably (less than one (1) per month) that noninvasive ambulatory monitoring (MCOT or external loop recorders) are unlikely to capture a diagnostic ECG.

The use of an implantable cardiac loop recorder not meeting the criteria as indicated in this policy is considered not medically necessary.

QLL

A remote interrogation device evaluation may be considered medically necessary once in 30 days with interim physician analysis and review.

Procedure Codes

0650T

33285

33286

93285

93291

93297

93298

E0616

Implantable Cardiac Loop Recorder for Post Cryptogenic Stroke or TIA

An implantable cardiac loop recorder, for post cryptogenic stroke or TIA, may be considered medically necessary when ALL of the following are met:

Diagnosis of a cryptogenic ischemic stroke or TIA should be based upon evaluation by a neurologist; and
The following standard tests are ALL required to establish diagnosis of cryptogenic stroke:
- Brain MRI or CT; and
- 12 lead ECG for AF detection; and
- 24-hour ECG monitoring for AF detection (e.g. Holter); and
- Transesophageal echocardiography (TEE); and
- CT angiography (head and neck) or magnetic resonance angiography (MRA) (head and neck) to rule out other causes of stroke; and
The individual is greater than or equal to 40 years of age; and
A documented collaborative treatment plan between neurologist and cardiologist; and
A TIA requires additional documentation of speech disturbance or limb weakness.

Not Medically Necessary

Implantable cardiac loop recorders post cryptogenic stroke or TIA are considered not medically necessary if an individual has ANY of the following:

The individual has a known etiology of stroke or TIA (i.e., large artery atherosclerosis, acute small artery occlusion with a lesion less than one (1) cm in diameter by CT or MRI; or
Evidence of high-risk cardiac or aortic arch source of embolism (left ventricular (LV) or left atrial (LA) thrombus) or 'smoke', emboligenic valvular lesion or tumor, patent foramen ovale (PFO) with extant source of venous thromboembolism, aortic arch plaque greater than three (3) mm thick or with mobile components; or
History of spontaneous deep vein thrombosis (DVT); or
Stroke of other determined cause such as the presence of non-atherosclerotic vasculopathy, hypercoagulable states (must be tested in individuals less than 55 years of age) and hematologic disorders; or
Untreated hyperthyroidism; or
MI less than one (1) month before stroke/TIA; or
Coronary bypass grafting (CABG) less than one (1) month before stroke/TIA; or
Valvular disease requiring immediate surgical intervention; or
Documented history of AF or atrial flutter; or
Presence of PFO and PFO is an indication to start oral anticoagulant therapy in accordance with European Stroke Organization (ESO) guidelines; or
The individual has a permanent indication for anticoagulation; or
The individual has a permanent contraindication for anticoagulation; or
Life expectancy less than one (1) year; or
The individual is indicated for implant with pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT) or implantable hemodynamic monitoring system.

An implantable cardiac loop recorder, for post cryptogenic stroke or TIA not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

0650T

33285

33286

E0616

Outpatient HCPCS (C Codes)

C1764

C1833

Diagnosis Codes

Covered Diagnosis Codes for procedure codes 93268, 93270, 93271, and 93272

I25.111

I25.118

I25.119

I25.701

I25.708

I25.709

I25.711

I25.718

I25.719

I25.721

I25.728

I25.729

I25.731

I25.738

I25.739

I25.751

I25.758

I25.759

I25.761

I25.768

I25.769

I25.791

I25.798

I25.799

I46.2

I46.8

I46.9

I47.0

I47.20

I47.29

I49.3

I49.01

I49.02

I50.1

Q24.6

Q25.21

Q25.29

Q25.40

Q25.41

Q25.42

Q25.43

Q25.44

Q25.45

Q25.46

Q25.47

Q25.48

Q25.49

R06.3

R06.83

R06.89

R07.82

R40.4

Covered Diagnosis Codes for procedure codes 93228, 93229, 93268, 93270, 93271, and 93272

I20.1

I20.81

I20.89

I20.9

I21.B

I44.0

I44.1

I44.2

I44.4

I44.5

I44.7

I44.30

I44.39

I44.60

I44.69

I45.0

I45.2

I45.3

I45.4

I45.5

I45.6

I45.10

I45.19

I45.89

I47.10

I47.11

I47.9

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.1

I49.49

I49.2

I49.5

R06.00

R06.01

R06.02

R06.09

R07.2

R07.9

R07.89

Covered Diagnosis Codes for procedure codes 33285, 33286, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93297, 93298, and E0616

I45.9

I45.81

I49.8

I49.9

I49.40

R00.1

R00.2

R42

R55

Covered Diagnosis Codes for procedure codes 33285, 33286, 93285, 93291,93297, 93298, and E0616

G45.9

I63.81

I63.89

I63.9

I63.50

I63.59

I63.313

I63.323

I63.333

I63.343

I63.413

I63.423

I63.433

I63.511

I63.512

I63.519

I63.521

I63.522

I63.529

I63.531

I63.532

I63.539

I63.541

I63.542

I63.549

I67.841

I67.848

Z45.09

Z86.73

Z95.818

Covered Diagnosis Codes for procedure codes 93228, and 93229

I21.11

I20.81

I20.89

I21.01

I21.02

I21.09

I21.9

I21.A1

I21.A9

I21.B

I22.0

I22.1

I22.9

I24.1

I24.89

I24.8

I24.9

I25.2

I25.5

I25.6

I49.2

R00.0

R00.8

R00.9

Z82.49

Z86.74

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Review Committee 9-26-2019 Coding update only

Internal Medical Review Committee 3-16-2020 Coding update only

Internal Medical Review Committee 9-21-2020 Annual Review

Internal Medical Review Committee 1-19-2021 Coding update:

Removed 0295T, 0296T, 0297T, 0298T and
Added 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248.

Internal Medical Review Committee 7-22-2021 Coding update - Effective July 01, 2021

Added 0650T

Internal Medical Review Committee 11-30-2021 Coding update - Effective January 01, 2022.

Added C1833

Internal Medical Review Committee 9-28-2022 Coding updated - Effective October 01, 2022

Removed Diagnosis code I47.2
Added Diagnosis codes I47.20 and I47.29

Internal Medical Policy Committee 9-12-2023 Annual review, no clinical content change

Internal Medical Review Committee 11-15-2023 Coding updated - Effective October 01, 2023

Added Diagnosis codes I20.81, I20.89, I21.B I47.10 and I14.11 to procedure codes 93228, 93229, 93268, 93270, 93271, and 93272.
Added Diagnosis codes I20.81, I20.89, I21.B and I24.89 to procedure codes 93228 and 93229.
Removed Diagnosis codes I21.8 and I47.1 from procedure codes 93228, 93229, 93268, 93270, 93271, 93272, 93228 and 93229.
Changed verbiage from MCOT to Implantable Cardiac Loop Recorder
Added HCPCS (C code) C1764 - Effective January 01, 2024

Internal Medical Review Committee 1-16-2024 Coding update - Effective January 01, 2024

Removed procedure code G2066
Archived policy - Effective March 04, 2024

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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