Cardiac event monitoring

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

Administrative process

Prior authorization is required for:

1. Mobile cardiovascular telemetry (MCT)
2. 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)
3. the new generations of FDA-approved ambulatory event monitors such as the iRhythm Zio® Patch and the CardioNet CardioKey cardiac event recorder.

Indications that are covered for mobile cardiovascular telemetry (MCT)

MCT is covered if the following criteria are met:

1. Must be ordered by a cardiologist;
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.
3. One of the following is present:
   1. Assessment of asymptomatic or symptomatic arrhythmia in patients who are status-post electrophysiology ablation procedure;
   2. To monitor patient’s response to medication prescribed to treat an arrhythmia;
   3. History of heart transplantation.

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 cardiac monitoring (non-implantable ambulatory event monitoring or mobile cardiac 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 daysnon-implantable ambulatory event monitoring or mobile cardiac 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 not 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.

Covered technologies that do not require prior authorization:

External unattended cardiac monitoring devices

Holter monitor (also known as continuous external unattended cardiac monitoring device) provides a continuous 24-hour (some models allow up to 72 hours) record of the electrocardiogram. The patient keeps a diary of all activities and symptoms.

Ambulatory event monitors (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

Technologies that are covered when criteria are met and require prior authorization:

External continuous attended cardiac monitoring devices

Mobile cardiovascular telemetry (MCT), (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 or even more frequently, and may be delivered by email or fax. Like an AEM, the duration of an MCT study is typically up to 30 days.

Implantable cardiac loop recorder (ILR) – Cardiac implantable loop recorders (ILRs) assess arrhythmias in symptomatic and asymptomatic patientsThe 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.

Not covered technologies:

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.

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

Implantable Loop Recorder codes – require prior authorization

33282	Implantation of patient-activated cardiac event recorder
C1764	Event recorder, cardiac (implantable)

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

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.

Bibliography available upon request.

This information is for most, but not all, CoOportunity Health 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.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.