Medical PolicyAmbulatory Event Monitors and Mobile Outpatient Cardiac Telemetry

Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies

Policy: Medicare Description References

Authorization Information Policy History

Policy Number: 347BCBSA Reference Number: 2.02.08

Related PoliciesNone

PolicyCommercial Members: Managed Care (HMO and POS), PPO, and Indemnity

The use of patient-activated or auto-activated external ambulatory event monitors may be MEDICALLYNECESSARY as a diagnostic alternative to Holter monitoring in the following situations: Patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of

cardiac arrhythmias (i.e., palpitations, dizziness, or syncope). Patients with atrial fibrillation who have been treated with catheter ablation, and in whom

discontinuation of systemic anticoagulation is being considered.

The use of implantable ambulatory event monitors either patient activated or auto-activated may beMEDICALLY NECESSARY only in the small subset of patients who experience recurrent symptoms soinfrequently that a prior trial of other external ambulatory event monitors has been unsuccessful.

Transtelephonic transmission of post-symptom electrocardiograms and cardiac event monitorsmay be MEDICALLY NECESSARY for the following indications, when used to evaluate patients inremote areas or long distances (such as 100 miles) from physicians capable of interpreting ECG: To detect, characterize, and document symptomatic transient arrhythmias To assess anti-arrhythmic drug efficiency, and To carry out early post-hospital monitoring of patients discharged after a myocardial infarction, if 24

hour coverage is provided. Such coverage must be performed by an experienced electrocardiogramtechnician receiving the calls (tapes and facsimiles do not count). These technicians must haveimmediate access to a physician, and have been instructed when and how to contact availablefacilities to assist the patient in case of emergencies.

This policy statement applies to plain EKGs (ECGs, electrocardiograms) only, transmittedelectronically for the purposes of interpretation, and

Transmitting devices must be capable of transmitting ECG leads I, II, and III, and transmissions mustbe comparable to readings obtained by conventional ECGs, to permit proper interpretation ofabnormal cardiac rhythms.

NOTE: Facsimiles and tapes are not reimbursed.

Outpatient cardiac telemetry (also known as mobile cardiac outpatient telemetry or MCOT) is NOT

MEDICALLY NECESSARY.

Continuous ambulatory monitors that record and store information for periods longer than 48 hours areINVESTIGATIONAL.

Other uses of ambulatory event monitors (including outpatient cardiac telemetry), including, but notlimited to, monitoring effectiveness of antiarrhythmic medications, for patients with cryptogenic stroke, anddetection of myocardial ischemia by detecting ST segment changes are INVESTIGATIONAL.

Medicare HMO BlueSM and Medicare PPO BlueSM MembersAmbulatory event monitoring, mobile outpatient cardiac telemetry and transtelephonic transmission ofpost-symptom electrocardiograms, and cardiac event monitors is covered for the following indications: To detect, characterize, and document symptomatic transient arrhythmias, To initiate, revise, or discontinue arrhythmic drug therapy, or To carry out early post-hospital monitoring of patients discharged after myocardial infarction (mobile

cardiac telemetry with real-time transmission, analysis, and response must be used for thisindication).

Ambulatory event monitoring, mobile outpatient cardiac telemetry and transtelephonic transmission ofpost-symptom electrocardiograms, and cardiac event monitors is not covered for any other indicationsthan those noted in the previous section.

Prior Authorization InformationSee below for situations where prior authorization may be required or may not be required.Yes indicates that prior authorization is required.No indicates that prior authorization is not required.

Outpatient InpatientCommercial Managed Care (HMO and POS) No n/aCommercial PPO and Indemnity No n/a

Medicare HMO BlueSM

No n/aMedicare PPO Blue

SMNo n/a

Other Information: Interpretation of the transmitted telephonic electrocardiogram must be performed by a Blue Cross

Blue Shield of Massachusetts contracted Cardiologist when referred for interpretation by a physician. Transmission of a telephonic electrocardiogram, when performed by an independent

physiological/diagnostic laboratory, must be rendered by a Blue Cross Blue Shield contractedIndependent Physiological/Diagnostic Lab.

CPT Codes / HCPCS Codes / ICD-9 CodesThe following codes are included below for informational purposes. Inclusion or exclusion of a code doesnot constitute or imply member coverage or provider reimbursement. Please refer to the member’scontract benefits in effect at the time of service to determine coverage or non-coverage as it applies to anindividual member. A draft of future ICD-10 Coding related to this document, as it might look today, isincluded below for your reference.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, anddiagnosis codes, including modifiers where applicable.

CPT Codes

CPT codes: Code Description33282 Implantation of patient-activated cardiac event monitor33284 Removal of an implantable, patient-activated cardiac event recorder93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording,

concurrent computerized real time data analysis and greater than 24 hours ofaccessible ECG data storage (retrievable with query) with ECG triggered and patientselected events transmitted to a remote attended surveillance center for up to 30 days;physician review and interpretation with report

93229 Wearable mobile cardiovascular telemetry with electrocardiographic recording,concurrent computerized real time data analysis and greater than 24 hours ofaccessible ECG data storage (retrievable with query) with ECG triggered and patientselected 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

93268 External patient and, when performed, auto activated electrocardiographic rhythmderived event recording with symptom-related memory loop with remote downloadcapability up to 30 days, 24-hour attended monitoring; includes transmission, physicianreview and interpretation

93270 External patient and, when performed, auto activated electrocardiographic rhythmderived event recording with symptom-related memory loop with remote downloadcapability up to 30 days, 24-hour attended monitoring; recording (includes connection,recording, and disconnection)

93271 External patient and, when performed, auto activated electrocardiographic rhythmderived event recording with symptom-related memory loop with remote downloadcapability up to 30 days, 24-hour attended monitoring; transmission and analysis

93272 External patient and, when performed, auto activated electrocardiographic rhythmderived event recording with symptom-related memory loop with remote downloadcapability up to 30 days, 24-hour attended monitoring; physician review andinterpretation

0295T External electrocardiographic recording for more than 48 hours up to 21 days bycontinuous rhythm recording and storage; includes recording, scanning analysis withreport, review and interpretation

0296T External electrocardiographic recording for more than 48 hours up to 21 days bycontinuous rhythm recording and storage; recording (includes connection and initialrecording)

0297T External electrocardiographic recording for more than 48 hours up to 21 days bycontinuous rhythm recording and storage; scanning analysis with report

0298T External electrocardiographic recording for more than 48 hours up to 21 days bycontinuous rhythm recording and storage; review and interpretation

ICD-9 Diagnosis Codes

ICD-9-CMdiagnosiscodes: Code Description426.9 Unspecified conduction disorder427.31 Atrial fibrillation427.60 Premature beats, unspecified427.89 Other specified cardiac dysrhythmias427.9 Cardiac dysrhythmia, unspecified780.2 Syncope and collapse780.4 Dizziness and giddiness

785.1 Palpitations

ICD-10 Diagnosis CodesICD-10-CMDiagnosiscodes: Code Description

I45.9 Conduction disorder, unspecified

I48.0 Paroxysmal atrial fibrillation

I48.2 Chronic atrial fibrillation

I48.91 Unspecified atrial fibrillation

I49.40 Unspecified premature depolarization

I49.8 Other specified cardiac arrhythmias

I49.9 Cardiac arrhythmia, unspecified

R00.1 Bradycardia, unspecified

R00.2 Palpitations

R42 Dizziness and giddiness

R55 Syncope and collapse

DescriptionAmbulatory Holter electrocardiography (EKG) is a widely used noninvasive test in which EKG iscontinuously recorded over an extended period of time, typically 24 to 48 hours, to evaluate symptomssuggestive of cardiac arrhythmias (i.e., palpitations, dizziness, or syncope). However, Holter monitoringwill be ineffective if a patient experiences infrequent symptoms. Ambulatory event monitors (AEMs) weredeveloped to provide longer periods of monitoring. In this technique, the recording device is either worncontinuously and activated only when the patient experiences symptoms, or carried by the patient andapplied and activated when symptoms are present. The recorded EKGs are then stored for futureanalysis or transmitted by telephone to a receiving station where the EKGs can then be analyzed. AEMscan be used for extended periods of time, typically up to a month until the patient experiences symptoms.Since the EKGs are recorded only during symptoms, there is good correlation with any underlyingarrhythmia. Conversely, if no EKG abnormality is noted, a noncardiac etiology of the patient's symptomscan be sought.

Several different types of AEMs are available:

Noncontinuous devices with memoryThese devices are carried by the patient and applied to the precordial area via nongel electrodes whenthe symptoms are occurring or, alternatively, a recording device may be worn on the wrist and thenactivated when symptoms are present. The limitation of these devices is that an arrhythmia of very shortduration would be difficult to record. In addition, noncontinuous devices require reasonable dexterity onthe part of the patient to apply the device correctly during a symptomatic period. This is a particularlimitation if the patient is incapacitated during symptomatic periods.

Continuous "memory loop" devicesThese sophisticated devices are worn continuously and are able to continuously store a single channel ofEKG data in a refreshed memory. If the patient activates the device, the EKG is then recorded from thememory loop for the preceding 30 to 90 seconds, and for the next minute or so. Therefore, these types ofdevices permit recording of the onset of arrhythmias and/or transient or incapacitating events.

Implantable continuous “memory loop” devicesAn implantable loop recorder device is inserted just under the patient’s skin in the chest area during anoutpatient surgical procedure and can be used for more than 1 year. When symptoms are felt, the patientplaces a hand-held activator over the recorder to activate the storage of cardiac rhythm.

Auto-triggered devicesAll of these devices require activation by the patient. More recently, auto-triggering technology hasbecome available, which can be adapted to memory loop devices. For example, event monitors can be

programmed to detect heart rates greater than 165 beats per minute, less than 40 beats per minute, or anasystole of greater than 3 seconds.

Mobile Cardiac Outpatient TelemetryAmbulatory event monitors store the recorded data, which are ultimately transmitted either to aphysician’s office or to a central recording station. In contrast, outpatient cardiac telemetry provides real-time monitoring and analysis. The referring physician can request the level and timing of response,ranging from daily reports to stat results.

Examples of ambulatory event monitors for cardiac monitoring include the Reveal® Insertable LoopRecorder from Medtronic the HEARTLink II system from Cardiac Telecom Corp., and the VST (Vital SignsTransmitter from Biowatch Medical. All ambulatory event monitors for cardiac monitoring are consideredinvestigational regardless of the commercial name, the manufacturer, or FDA approval status except asnoted in the policy statement.

SummaryA number of studies have indicated that autotrigger event monitors detect additional episodes ofarrhythmias compared to Holter monitoring or patient-triggered devices. This evidence has led to theacceptance of autotrigger event monitors as the gold standard for detecting arrhythmias that occurinfrequently. There is also evidence that autotrigger devices can pick up asymptomatic episodes of atrialfibrillation in patients treated with catheter ablation and that identifying asymptomatic episodes may leadto modifications in treatment. For patients with cryptogenic stroke, longer monitoring periods will detectadditional episodes of atrial fibrillation, but the evidence is not sufficient to conclude that outcomes areimproved.

Newer continuous monitoring devices are available that use novel technology and record information forlonger periods than a Holter monitor, eg, up to 2 weeks. There is a lack of evidence on the quality ofrecording from these devices, and on the detection rate for cardiac arrhythmias. Due to a lack ofevidence, these continuous monitoring devices that record for longer time periods are consideredinvestigational.

Mobile cardiac outpatient telemetry (MCOT) is another option for long-term cardiac monitoring. Thecurrent evidence on MCOT establishes that it does record cardiac electric signals, without patientactivation, for subsequent analysis. Currently, the literature does not provide any adequate comparativedata for MCOT compared to the autotrigger device. One retrospective, uncontrolled study reported thatonly a small minority of events (1%) detected by MCOT were potentially emergent. None of the availablestudies have clearly shown an improvement in clinical utility as a result of using MCOT. Further studiesare needed to compare MCOT with the autotrigger loop recorder in order to determine whether the fasterresponse possible with real-time monitoring leads to improved outcomes.

Thus, at the present time, outcomes from use of a MCOT are expected to be equivalent to outcomes fromuse of autotrigger or other types of devices. As a result, in situations where MCOT is more expensivethan alternate devices such as the autotrigger device, MCOT is considered not medically necessary.

Policy HistoryDate Action7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015.6/2014 Language on MCOT clarified4/2014 BCBSA National medical policy review.

Revised to change “loop monitors” to “ambulatory event monitors” and add “The policystatement on outpatient cardiac telemetry was reworded and language was added thatthe least costly alternative may be considered medically necessary.” Effective 4/1/2014.

3/2014 BCBSA National medical policy review.Medically necessary criteria for implantable loop monitors revised from “…a prior trial ofHolter monitor and other external ambulatory event monitors has been unsuccessful” to“…a prior trial of other external ambulatory event monitors has been unsuccessful.”

Effective 3/1/2014.1/2014 New references added from BCBSA National medical policy.6/1/2013 BCBSA National medical policy review.

Changes to policy statements.11/2011-4/2012

Medical policy ICD 10 remediation: Formatting, editing and coding updates.No changes to policy statements.

4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology.No changes to policy statements.

10/2010 BCBSA National medical policy review.Changes to policy statements.

4/2010 Reviewed - Medical Policy Group - Cardiology and Pulmonology.No changes to policy statements.

12/31/2009 BCBSA National medical policy review.Changes to policy statements.

7/2009 BCBSA National medical policy review.Changes to policy statements.

4/2009 Reviewed - Medical Policy Group - Cardiology and Pulmonology.No changes to policy statements.

3/2009 BCBSA National medical policy review.No changes to policy statements.

4/2008 Reviewed - Medical Policy Group - Cardiology and Pulmonology.No changes to policy statements.

11/2007 BCBSA National medical policy review.No changes to policy statements.

6/2007 BCBSA National medical policy review.No changes to policy statements.

5/2007 BCBSA National medical policy review.Changes to policy statements.

4/2007 Reviewed - Medical Policy Group - Cardiology and Pulmonology.No changes to policy statements.

Information Pertaining to All Blue Cross Blue Shield Medical PoliciesClick on any of the following terms to access the relevant information:Medical Policy Terms of UseManaged Care GuidelinesIndemnity/PPO GuidelinesClinical Exception ProcessMedical Technology Assessment Guidelines

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