I. External cardiac event monitors (ambulatory event monitor (AEM) (93268, 93270, 93271, 93272)or external loop recorder) in adults (≥ 18 years of age) may be considered medically necessary for ANY of the following:

A.  member has infrequent symptoms suggestive of any arrhythmia such as palpitations, dizziness, near syncope or syncope that occur less frequently than every 48 hours making it unlikely to be diagnosed by Holter monitoring or hospital telemetry, or when these studies are non-diagnostic OR

B.  to assess the results after an ablation procedure performed for an arrhythmia OR

C.  to assess the benefit after initiating drug therapy for an arrhythmia OR

D.  to document the recurrence of an arrhythmia after discontinuation of drug therapy OR

E.  member with cryptogenic stroke in whom atrial fibrillation is suspected to be the cause and a 24-hour Holter monitor or hospital telemetry is non-diagnostic OR

F.  to assess for silent myocardial ischemia by documenting ST segment depression in a member with known suspected coronary heart disease when a 24-hour Holter or hospital telemetry is non-diagnostic. 

II.   External cardiac event monitors (ambulatory event monitor AEM, or external loop recorder) (93268, 93270, 93271, 93272) in all children (less than 18 years of age ) OR in adults with Congenital Heart Disease may be considered medically necessary for ANY of the following:

A.  for diagnosis when a member has symptoms suggestive of an arrhythmia such as palpitations, near syncope or syncope regardless of the frequency of occurrence, OR

B.  to assess the benefit after initiating drug therapy for an arrhythmia OR

C.  to document the recurrence of an arrhythmia after discontinuation of drug therapy OR

D.  to assess the benefit after initiating treatment with pacemaker or ICD for an arrhythmia.

III.  External cardiac event monitors (ambulatory event monitors or external loop recorders) are considered investigational for all other indications not listed above because their effectiveness for other indications has not been established.

IV.  Ziopatch or BardyDX for external long-term (93241-93244 = up through 6 days) OR (93245-93248 = 7 up to 15 days)  continuous ECG monitoring may be considered medically necessary for ANY of the following:

A.  member has infrequent symptoms suggestive of any arrhythmia such as palpitations, dizziness, near syncope or syncope that occur less frequently than every 48 hours making it unlikely to be diagnosed by Holter monitoring or hospital telemetry, or when these studies are non-diagnostic OR

B.  to assess the results after an ablation procedure performed for an arrhythmia OR

C.  to assess the benefit after initiating drug therapy for an arrhythmia OR

D.  to document the recurrence of an arrhythmia after discontinuation of drug therapy OR

E.  member with cryptogenic stroke in whom atrial fibrillation is suspected to be the cause and a 24-hour Holter monitor or hospital telemetry is non-diagnostic OR

F.  to assess for silent myocardial ischemia by documenting ST segment depression in a member with known or suspected coronary heart disease when a 24-hour Holter or hospital telemetry is non-diagnostic. 

V.  Ziopatch or BardyDX for external long-term (greater than 48 hours) continuous ECG monitoring in children may be considered medically necessary for the rare instances where it could be useful in rare pediatric patient with atrial fibrillation.

VI. Implantable loop recorders in adults and children may be considered medically necessary for ANY of the following:

A.  member has recurrent and unexplained symptoms suggestive of an arrhythmia such as palpitations, dizziness, near syncope or syncope that occur less frequently than once a month making it unlikely to be diagnosed by external cardiac event monitoring or when these studies are non-diagnostic OR

B.  to assess the results after an ablation procedure performed for an arrhythmia OR

C.  member with cryptogenic stroke with whom atrial fibrillation is suspected to be the cause and a 24-hour Holter monitor or hospital telemetry is non-diagnostic. 

D.  genetically based arrhythmia conditions (LongQT Syndrome, Short QT Syndrome, Brugada Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) in whom:

1. there is suspicion of symptoms only while sleeping OR

2. the family history is that of cardiac arrest while sleeping OR

E.  patients with developmental delays precluding accurate symptom description but in whom there is sufficient reason (clinical signs/symptoms, family history) to believe the patient is at risk for an arrhythmia.

VII.  Implantable loop recorders are considered investigational for all other indications not listed above because their effectiveness for other indications has not been established.

VIII.  Mobile Cardiac Outpatient Telemetry (MCOT) (93228, 93229) may be considered medically necessary for ANY of the following:

A.  member has recurrent and unexplained symptoms suggestive of an arrhythmia such as palpitations, dizziness, near syncope or syncope and an external cardiac event monitor or implantable loop recorder is non-diagnostic OR

B.  member with cryptogenic stroke in whom atrial fibrillation is suspected to be the cause and an external cardiac event monitor or implantable loop recorder is non-diagnostic. 

IX.  Mobile Cardiac Outpatient Telemetry (MCOT) is considered investigational for all other indications not listed above because their effectiveness for other indications has not been established.

X.  Mobile applications using smart devices (e.g. Kardia Mobile, AliveCore Mobile, AliveCor Heart Monitoring (iPhoneECG), Visi Mobile Monitoring System, iHEART, CardioPatch, Biotronik BioMonitor, and BodyGuardian Remote Monitoring System) for the use of diagnosing arrhythmias (e.g. atrial fibrillation) are considered investigational because their clinical value and effectiveness have not been established.  These mobile applications are not considered DME per the FDA. 

IX.  The intracardiac ischemic monitoring system (C1833) is considered investigational for all indications including but not limited to the detection of acute myocardial ischemic events as there is insufficient clinical evidence of safety and/or efficacy.

Although some patients with arrhythmias may experience palpitations, weakness, dizziness, or fainting, other patients may have no symptoms at all.  Effective treatment requires an accurate diagnosis.  This can be difficult since arrhythmias can occur infrequently and unpredictably and may be asymptomatic.  The type and duration of ambulatory electrocardiography (ECG) monitoring is dictated by the frequency of symptoms.

Non-implantable cardiac event monitors are portable devices that record heart rhythms intermittently for up to 30 days.  These devices capture ECG data before, during and after the time of activation.  Recording can be patient activated when symptoms occur or automatically triggered based on a computer algorithm designed to detect arrhythmias.  These devices are used to record infrequent or irregular events.

The Ziopatch is a small adhesive patch that does not have a lead, wires, or batteries.  This makes it more convenient and less obtrusive than a traditional Holter monitor.  It is capable of continuously recording an ECG for up to 14 days, although only a single lead is recorded.

The implantable loop recorder (ILR) is a subcutaneous monitoring device for the detection of cardiac arrhythmias.  ILRs are most commonly utilized in the evaluation of palpitations or syncope of undetermined etiology, particularly when symptoms are infrequent (eg. less than once per month) and/or other ambulatory monitoring has been unrevealing or inconclusive.  The ILR offers the ability to monitor for cardiac arrhythmias for prolonged periods of months to years.

External mobile cardiovascular telemetry consists of a monitor that continuously records the electrocardiographic rhythm from external electrodes placed on the patient's body for up to 30 days. Segments of the ECG data are automatically (i.e. without patient intervention) transmitted to a remote surveillance location by cellular or landline telephone signal.  The transmitted events are triggered automatically by preprogrammed algorithms or by the patient during a symptomatic episode.  There is continuous, real-time data analysis in the device and attended surveillance of the transmitted rhythm segments by a surveillance center technician.  The surveillance center technician reviews the data and notifies the physician depending on the prescribed criteria (America Medical Association (AMA, 2011).  These devices are used to record suspected asymptomatic arrhythmias.