Ambulatory Electrocardiograph Monitoring Form

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Ambulatory Electrocardiograph Monitoring - Medical Policy Updated Revision Effective: 7/1/2025 Policy Number: UM375POL

Approval Date:

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

In contrast to the standard electrocardiogram (ECG), which provides a brief sample of cardiac electrical activity over 10 seconds, ambulatory ECG monitoring provides a view of ECG data over an extended period of time, thereby permitting evaluation of dynamic and transient cardiac electrical phenomena. The most common ambulatory ECG application is in the diagnosis and assessment of cardiac arrhythmias or conduction abnormalities (symptomatic or asymptomatic) or the presence of potential arrhythmias (such as in patients with syncope or presyncope); however, ambulatory ECG also has a role in stratification of certain cardiomyopathies, in assessing the effectiveness of arrhythmia therapy, and in the evaluation of silent ischemia. Ambulatory ECG monitoring, which can be performed using a variety of techniques for as short as 24 to 48 hours and for as long as months to years, offers the opportunity to review cardiac ECG data during routine activity, as well as during periods of physical and psychological stress. Ambulatory ECG monitoring for longer periods (when compared with standard ECG) is more sensitive for detecting spontaneous, often highly variable cardiac arrhythmias or conduction abnormalities.

Improvements in solid-state digital technology have enhanced trans-telephonic transmission of electrocardiography (ECG) data and increased the accuracy of software-based analysis systems. These advances, in addition to better signal quality and greater computer arrhythmia interpretation capabilities, have opened new potential uses for Ambulatory Electrocardiograph (AECG). Traditional uses of AECG for arrhythmia detection have expanded as the result of increased use of multichannel and telemetered signals.

Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. There are no MassHealth guidelines for Ambulatory Electrocardiograph Monitoring

Medicare:

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Refer to criteria under Policy section in this medical policy. Health New England criteria takes into consideration National Coverage Determination (NCD) for Ambulatory Electrocardiograph Monitoring, 20.15 Electrocardiographic Services. https://www.cms.gov/medicare-coverage-database/search.aspx

Policy

Medically Necessary:

I. HNE requires Prior Authorization for External Ambulatory Electrocardiograph (AECG) Monitoring in the following situations:

A. External AECG monitoring devices worn for over 30 days as listed in the policy guidelines including Mobile Cardiovascular Outpatient Telemetry (MCOT) and External Loop Recorders.

B. More than two MCOT or external loop recordings in 1 calendar year.

II. HNE requires Prior Authorization for Implantable Ambulatory Electrocardiographic (AECG) monitoring, either patient activated or auto activated. These devices are considered MEDICALLY NECESSARY in the following situations:

A. In the small subset of patients who experience recurrent symptoms (unexplained episodes of syncope, presyncope, dizziness or palpitations) so infrequently that a prior trial of an External AECG (either 3 day Holter or 14-day monitor) has been unsuccessful; OR B. In patients who require long-term monitoring for Atrial fibrillation or Flutter, OR

C. In patients with the possibility of Atrial fibrillation or Flutter, such as in members with cryptogenic stroke where a definitive source of cardio-embolism, large or small artery atherosclerosis have not been identified and external cardiac monitoring (Holter monitor for 24-48 hours or Telemetry or long-term external AECG) have been non-diagnostic. III. HNE covers interrogation and analysis of MEDICALLY NECESSARY Implanted AECG monitoring device that has met the criteria above, by a physician or other qualified healthcare professional, once every 30 days, up to 3 years from the date of implantation.

IV. HNE covers interrogation and analysis of MEDICALLY NECESSARY Implanted AECG monitoring device that has met the criteria above, by a physician or other qualified healthcare professional beyond 3 years from the date of implantation if there is an ongoing medical necessity supported by clinical documentation.

V. Implantable AECG monitoring used in lieu of other monitoring for the convenience of the patient, provider, or family are considered NOT MEDICALLY NECESSARY.

VI. All other uses of implantable AECG are considered EXPERIMENTAL and INVESTIGATIONAL.

VI. Following are monitors considered EXPERIMENTAL and INVESTIGATIONAL:

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A. CardioPatch. B. Kardia Mobile. C. Self-monitoring ECG technologies or Visi Mobile Monitoring system. D. Biotronik BioMonitor.

VII. HNE does not require Prior Authorization for the following External Ambulatory Electrocardiograph (AECG) Monitoring.

A. Long-term (greater than 48 hours, up to 30 days) external “patch” ECG monitoring by continuous rhythm recording and storage (e.g., Zio Patch® and similar devices) is medically necessary for the evaluation of patients suspected of having an arrhythmia (CPT codes 93241-93248 are non-covered by MassHealth).

Policy Guidelines and Definitions

I. Mobile cardiovascular outpatient telemetry (MCOT) [e.g., CardioNet® MCOT, Zio AT] is considered MEDICALLY NECESSARY for evaluation of patients with:

A. Recurrent unexplained episodes of syncope, presyncope, dizziness or palpitations when the following conditions are met:

1. The cause of the symptoms is suspected to be cardiac arrhythmia;

   AND

2. Symptoms are less than daily.

   OR

   B. Member with suspected atrial fibrillation as a cause for a brain infarction not attributed to a definite source of cardio embolism, large or small artery atherosclerosis and non-diagnostic Holter monitor for 48-hours.

   • Mobile cardiovascular outpatient telemetry performed in lieu of other monitoring for the convenience of the patient, provider, or family are considered NOT MEDICALLY NECESSARY.

   • All other uses of mobile cardiovascular outpatient telemetry are considered EXPERIMENTAL and INVESTIGATIONAL.

   II. External cardiac event detection monitoring (e.g., external loop monitoring up to 30 days) is considered MEDICALLY NECESSARY when:

   A. Documentation confirms symptoms (palpitations, dizziness, presyncope, syncope) occur infrequently that arrhythmia is unlikely to be diagnosed by a 24- or 48-hour Holter monitor AND results of this testing will provide diagnostic or treatment information necessary for the management of the member beyond what would be provided by the continuous 24- or 48-hour Holter monitor;

   OR

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B. There is history of atrial fibrillation and atrial flutter for the assessment for atrial fib/flutter burden that would help with medical decision making such as rate control and anticoagulation.

• External cardiac event detection monitoring performed in lieu of other monitoring for the convenience of the patient, provider, or family is considered not medically necessary.

• All other uses of external cardiac event detection monitoring are considered investigational.

Age-Specific Criteria:

Other than medical necessity criteria noted above, one or more of the following age-specific criteria must be met for monitoring devices to be considered medically necessary:

I. Adults:

A. Evaluation of infrequent recurrent symptoms (e.g., presyncope, syncope, lightheadedness, palpitations, shortness of breath, chest pains or dizziness) that may be associated with arrhythmia

B. Evaluation of members with unexplained recurrent palpitation after complete examination

C. Monitoring members who have had surgical or catheter ablation of atrial fibrillation when discontinuation of systemic anticoagulation is being considered

D. Assessment of individuals who have had a history of cryptogenic stroke along with evidence of prior non- diagnostic tests

E. Evaluation of members with idiopathic hypertrophic or dilated cardiomyopathies to detect arrhythmias

II. Pediatric:

A. Antiarrhythmic drug efficacy, during rapid somatic growth

B. Asymptomatic congenital atrioventricular block, non-paced

C. Documented or potential long QT syndromes (LQTS)

D. Hypertrophic or dilated cardiac myopathies

E. Syncope, near-syncope or sustained palpitations in the absence of a reasonable explanation and where there is no overt clinical evidence of heart disease

F. Palpitations in members with previous surgery for congenital heart disease and significant residual hemodynamic abnormalities

G. Previously documented arrhythmia or pacemaker dependency

H. Syncope, near syncope associated with exertion or dizziness with known heart disease

Definitions:

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• Holter monitoring: Continuously records all ECG data for a period of 24–48 hours

• Continuous AECG (ambulatory ECG) “patch” monitoring: Used for periods longer than 2 days (e.g., Zio® Patch, Preventice®, Vital Connect® and others). These devices are single-use AECG monitors which do not require the patient to apply and remove adhesive leads on a daily basis or recharge batteries frequently. These devices have the capability of collecting all rhythm data for up to 14 days.

• External cardiac event detection monitoring (e.g., external loop monitoring): An external loop monitor has the capability to monitor an individual for long durations (e.g., up to 30 days) with a higher chance of providing a diagnosis to those whose symptoms occur infrequently. The auto-trigger function is used to detect asymptomatic arrhythmias including paroxysmal atrial fibrillation. It is recommended for those with infrequent short-duration transient symptoms, reoccurring over weeks or months. One disadvantage of these devices is that of limited device memory. They generally store 30 seconds to 2 minutes before and after an event, either patient or auto-triggered. After the device is activated the recording is transmitted telephonically to an attended surveillance center where a technician is available to review the transmitted data 24 hours a day.
Physicians are available and are notified depending on the prescribed criteria.

• Implantable loop monitors/recorders (ILR): Implanted directly under the skin. Device is a single-lead, ECG monitoring device used for diagnosis in patients with recurrent unexplained episodes of palpitations or syncope. Rarely the preferred initial test for ambulatory ECG monitoring. Electrophysiological study (EPS) is not a prerequisite to insertion of implantable loop recorder.

• Mobile cardiac outpatient telemetry monitoring (e.g., CardioNet® MCOT, Zio AT) or automatic outpatient cardiac monitoring or real time cardiac monitoring: Device can be used for up to 30 days and is automatic, continuous and requires no patient activation. The device records heart rhythms continuously. It holds up to 96 hours of memory and allows providers to capture significant arrhythmic events, even when no symptoms are experienced. When arrhythmia occurs, segments of EKG data are automatically transmitted to an attended surveillance center where a technician is available to review the transmitted data 24 hours a day. Physicians are available and are notified depending on the prescribed criteria.

• Electrophysiology study (EPS): Tests that help physicians understand from which area of the heart an abnormal rhythm (arrhythmia) may originate. EPS usually take place in an electrophysiology (EP) lab or a cardiac catheterization lab while the individual is mildly sedated. A thin tube (catheter) is inserted into a blood vessel leading to the heart. Catheter contains electrodes that allow the physician to send electrical signals to record the electrical activity of the heart. EPS can diagnose arrhythmias, evaluate the effectiveness of antiarrhythmic medications, assess for risk of cardiac arrest or determine other treatment options (i.e., pacemaker, implantable cardiac defibrillator).

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Coding Guidance

Codes by Service and Prior Authorization (PA). Cardiovascular Monitoring Services Service Technical Professional Hook up Global PA Holter 93226 93227 93225 93224 NO Long-term 7 Day 93243 93244 93242 93241 NO Long-term 14 Day 93247 93248 93246 93245 NO MCOT 30 days and fewer 93229 93228 Included in 93229 None NO External cardiac event detection (External Loop) monitoring up to 30 days 93271 93272 93270 93268 NO Implantable Loop Recorder/ Subcutaneous Cardiac Rhythm Monitor System PA Device Evaluation in Office 93285 93291

YES Device Evaluation Remote

93298 0650T

YES Insertion of Implantable Loop Recorder 33285

YES

CPT Codes

Description PA 33285 Insertion, subcutaneous cardiac rhythm monitor, including programming YES 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional NO 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) NO 93226 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report NO 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional NO 93228
Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report.

NO

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93229

Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with 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. NO 93241

External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation
NO 93242

External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm recording and storage; recording (includes connection and initial recording) (Effective 01/01/21) NO 93243

External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm recording and storage; scanning analysis with report NO 93244

External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation NO 93245

External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation NO 93246

External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; recording (includes connection and initial recording) NO 93247

External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; scanning analysis with report NO 93248

External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; review and interpretation NO 93268

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download
NO 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) NO 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 and analysis
NO 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
NO 93285 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable loop recorder system YES

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93291 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional , includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis YES 93298 Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified healthcare professional YES 0650T Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professional YES

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

UpToDate: Ambulatory ECG monitoring. Literature review current through Dec 2023. This topic last updated on Nov 29, 2022. https://www.uptodate.com/contents/ambulatory-ecg- monitoring?search=ambulatory%20cardiac%20monitoring&source=searchresult&selectedTitle=1~150&usag etype=default&display_rank=1 (Subscription required)

Hayes: Zio Patch (IRhythm Technologies Inc.) Long-Term Ambulatory Cardiac Rhythm Monitoring in Pediatric Patients. Evidence Analysis Research Brief May 12, 2022. blob:https://evidence.hayesinc.com/d59b1cc4-2f5c-4a95-a434-c3475c2230f4 (Subscription required).

Hayes: Implantable Cardiac Loop Recorders for Diagnosis and Management of Syncope in Adults
blob:https://evidence.hayesinc.com/44846247-f0f3-4ec1-8a0e-c85c7c609f7f (Subscription required).

Heart-Rhythm Monitoring for evaluation of cryptogenic stroke. Hooman Kamel, M.D. NEJM 2014; 370:2532-2533 https://www.nejm.org/doi/full/10.1056/NEJMe1405046

Atrial Fibrillation and Stroke. Hani Essa , Andrew M Hill, Gregory Y H Lip. Card Electrophysiol Clin. 2021 Mar;13(1) 243- 255

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https://pubmed.ncbi.nlm.nih.gov/33516402/

Newer technologies for detection of atrial fibrillation. BJM 2018;363:k3946 https://www.bmj.com/content/363/bmj.k3946

American College of Cardiology: Atrial Fibrillation Burden: AHA Scientific Statement April 23, 2018 https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2018/04/23/14/06/Atrial-Fibrillation-Burden- Moving-Beyond

Diagnostic and therapeutic value of implantable loop recorder: A tertiary care center experience (January 2019). Padmanabhan, D, Kancharla, K, El-Harasis, M, et al. https://pubmed.ncbi.nlm.nih.gov/30357866/

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update

10/2010 Initial Policy Date 3/2022 Policy Language Updated. 1/2023 Policy Language Updated. Removed prior authorization from 93241, 93242, 93243, 93244, 93245, 93246, 93247, and 93248. 3/2023 Policy language updated. PA removed for all monitors 30 days and fewer except MCOT or Loop monitors greater than 30 days or more than two episodes of monitoring per calendar year 7/2023 Removed requirement for Non-diagnostic Holter monitor.
Removed “Assessment of individuals with documented coronary artery disease (CAD) for silent myocardial ischemia” from Age-Specific Criteria section.
9/2023 Added CPT code 33285 1/2024 Added Line of Business section 02/2024 Title change from Ambulatory Cardiac Monitoring.
Minor criteria changes to the Implantable Ambulatory Electrocardiographic (AECG) section.
Added CPT 0605T. 7/2024 Removed G2066. 7/2024 Added criteria for interrogation and analysis of Implanted AECG monitoring device beyond 3 years from date of implantation.
4/2025 Corrected CPT code for Programming Device Evaluation to 0650T.
Minor changes.

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Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.