CMS Self-Contained Pacemaker Monitors Form

Self-contained pacemaker monitors are accepted devices for monitoring cardiac pacemakers. Accordingly, program payment may be made for the rental or purchase of either of the following pacemaker monitors when a physician for a patient prescribes it with a cardiac pacemaker:

A. Digital Electronic Pacemaker Monitor

This device provides the patient with an instantaneous digital readout of his pacemaker pulse rate. Use of this device does not involve professional services until there has been a change of five pulses (or more) per minute above or below the initial rate of the pacemaker; when such change occurs, the patient contacts his physician.

B. Audible/Visible Signal Pacemaker Monitor

This device produces an audible and visible signal which indicates the pacemaker rate. Use of this device does not involve professional services until a change occurs in these signals; at such time, the patient contacts his physician.

NOTE: The design of the self-contained pacemaker monitor makes it possible for the patient to monitor his pacemaker periodically and minimizes the need for regular visits to the outpatient department of the provider.

Therefore, documentation of the medical necessity for pacemaker evaluation in the outpatient department of the provider should be obtained where such evaluation is employed in addition to the self-contained pacemaker monitor used by the patient in his home.