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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-93000-05

Original Effective Date: 11/15/01

Reviewed: 08/25/16

Revised: 09/15/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Cardiac Monitoring Devices

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Ambulatory cardiac monitoring with a variety of devices allows for the evaluation of cardiac electrical activity over time, in contrast to a static electrocardiogram (ECG), which only permits the detection of abnormalities in cardiac electrical activity at a single point in time. Cardiac monitoring is routinely used in the inpatient setting for the purpose of detecting acute changes in heart rate or rhythm that may need urgent response. For some clinical conditions, a more prolonged period of monitoring in the ambulatory setting is needed to detect heart rate or rhythm abnormalities that may occur infrequently. These cases may include the diagnosis of arrhythmias in patients with signs and symptoms suggestive of arrhythmias. In addition, ambulatory cardiac monitoring may be used for evaluation of paroxysmal atrial fibrillation (AF).

Ambulatory event monitors (AEMs) were developed to provide longer periods of monitoring. In this technique the recording device is worn continuously and activated only when the patient experiences symptoms or is carried by the patient and applied and activated when symptoms are present. The recorded EKGs are then stored for future analysis or transmitted by telephone to a receiving station, e.g., a doctor's office, hospital, or cardiac monitoring service, where the EKGs can then be analyzed. AEMs can 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 underlying arrhythmia. Conversely, if no EKG abnormality is noted, a noncardiac etiology of the patient's symptoms can be sought.

Real-time Continuous Attended Remote Cardiac Monitoring Systems: Unlike ambulatory event monitors that store the recorded data, which are ultimately transmitted either to a physician’s office or to a central recording station, real-time continuous attended remote cardiac monitoring systems automatically record and transmit arrhythmia event data from the patient to a qualified healthcare professional attending the monitor at a clinic or hospital. These systems allow automatic wireless transmission of abnormal ECG waveforms from the patient’s home to an attended monitoring center at the time of the arrhythmia event.

Omnicardiogram/Cardiointegram (CIG):An omnicardiogram/cardiointegram device consists of a microcomputer, which receives output from a standard electrocardiogram (ECG) and transforms it to produce a graphic representation of heart electrophysiologic signals. This procedure is used primarily as a substitute for Exercise Tolerance Testing with Thallium Imaging in patients for whom a resting ECG may be inadequate to identify changes compatible with coronary artery disease.

Cardiac Hemodynamic Monitoring (CardioMEMS™ HF System): The FDA approved the CardioMEMS HF System through the premarket approval (PMA) process in May 2014. The system utilizes a pulmonary artery sensor device and is indicated for measuring pulmonary artery pressure and heart rate in individuals who have undergone hospitalization for New York Heart Association (NYHA) Class III heart failure in the past year. The CardioMEMS System allows the hemodynamic data to be transmitted wirelessly to clinical staff who are monitoring and managing heart failure, with the specific intent to reduce hospitalizations due to heart failure. The System is contraindicated for individuals who are unable to take antiplatelet or anticoagulants for 1 month following the implantation procedure.

POSITION STATEMENT:

The use of patient-activated or auto-activated (i.e., auto-triggered) external ambulatory event monitors or continuous ambulatory monitors that record and store information for periods longer than 48 hours meets the definition of medical necessity as a diagnostic alternative to Holter monitoring in the following situations:

Members who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope);

Members with atrial fibrillation who have been treated with catheter ablation, and in whom discontinuation of systemic anticoagulation is being considered; OR

Members with cryptogenic stroke who have a negative standard work-up for atrial fibrillation including a 24-hour Holter monitor.

The use of implantable ambulatory event monitors, either patient-activated or auto-activated, meets the definition of medical necessity in the following situations:

• In the small subset of members who experience recurrent symptoms so infrequently that a prior trial of Holter monitor and other external ambulatory event monitors has been unsuccessful; OR

• In members who require long-term monitoring for atrial fibrillation or possible atrial fibrillation.

The use of outpatient cardiac telemetry (also known as mobile cardiac outpatient telemetry) is considered experimental or investigational as a diagnostic alternative to ambulatory event monitors in members who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (ie, palpitations, dizziness, presyncope, syncope). Further studies are needed to determine the efficacy of these devices in comparison to other external ambulatory cardiac monitoring.

Other uses of ambulatory event monitors, including outpatient cardiac telemetry, are considered experimental or investigational, including but not limited to: monitoring the effectiveness of antiarrhythmic therapy and detection of myocardial ischemia by detecting ST segment changes. There is insufficient evidence to validate these applications.

Omnicardiogram/Cardiointegram (CIG), a technique intended to detect abnormalities in the standard twelve-lead electrocardiogram, which are not identifiable by competent routine interpretation in patients at risk of cardiac ischemia, is considered experimental or investigational because there is insufficient evidence to support conclusions regarding its efficacy/sensitivity and value as a diagnostic tool.

The implantation of a pressure sensor into the pulmonary artery for wireless ambulatory monitoring (i.e. CardioMEMS™ HF System) is considered experimental or investigational for heart failure and all other indications. There is insufficient evidence to permit conclusions on clinical utility and net health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe ambulatory event monitoring and mobile outpatient cardiac telemetry:

CPT Coding:

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; recording (includes connection and initial recording)

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

33282

Implantation of patient-activated cardiac event recorder. [insertable loop recorder]

33284

Removal of an implantable, patient-activated cardiac event recorder. [insertable loop recorder]

93228

External 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; review and interpretation with report by a physician or other qualified health care professional (investigational)

93229

External 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 transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional (investigational)

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, review and interpretation by a physician or other qualified health care professional

93270

External patient electrocardiographic rhythm derived event recording with pre-symptom memory loop, 24-hour attended monitoring, per 30-day period of time; 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; transmissions, 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; review and interpretation by a physician or other qualified health care professional

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

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

93298

Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional

93299

Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular system or implantable loop recorder system, remote data acquisitions(s), receipt of transmissions and technician review, technical support and distribution of results

HCPCS Coding:

E0616

Implantable cardiac event recorder with memory, activator and programmer

S9025

Omnicardiogram/cardiointegram (investigational)

ICD-10 Diagnoses Codes That Support Medical Necessity for codes 33282, 33284, 93268, 93270, 93271, 93272, and E0616: (Effective 10/01/15)

I44.0I44.7

Atrioventricular and left bundle-branch block

I45.0I45.9

Other conduction disorders

I47.0I47.9

Paroxysmal tachycardia

I48.0I48.1

Atrial fibrillation and flutter

I49.01I49.9

Other cardiac arrhythmias

I63.9

Cerebral infarction, unspecified

R00.2

Palpitations

R42

Dizziness and giddiness

R55

Syncope and collapse

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, conservative treatment plan, physician progress notes, and all laboratory studies.

Documentation Table

LOINC Codes

LOINC
Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0,

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Medication Current

19009-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, Discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date:

Electrocardiographic (EKG) Services, (20.15) located at cms.gov.

Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test, (20.27) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

Cardiointegram: a device that consists of a microcomputer which receives output from a standard electrocardiogram (ECG) and transforms it to produce a graphic representation of heart electrophysiologic signals. This procedure is used primarily as a substitute for exercise tolerance testing with thallium imaging in patients for whom a resting ECG may be inadequate to identify changes compatible with coronary artery disease.

Omnicardiogram: see cardiointegram.

Presyncope: faintness.

Syncope: a sudden but transient total loss of consciousness with spontaneous resolution.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Accessed 02/03/12.
  2. Adamson PB, et al. Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction. Circ Heart Fail 2014 Nov;7(6):935-44.
  3. Abraham WT, et al; Sustained Efficacy of Pulmonary Artery Pressure To Guide Adjustment of Chronic Heart Failure Therapy: Complete Follow-Up Results from the CHAMPION Trial. Lancet. 2016 Jan 30;387(10017):453-61.
  4. American College of Cardiology – Ambulatory External Electrocardiographic Monitoring; Focus on Atrial Fibrillation. Suneet Mittal, MD, Colin Movsowitz, MBCHB, Jonathan S. Steinberg, MD. JACC Vol. 58, No. 17, 2011. October 18, 2011:1741–9 (Accessed 01/21/2014).
  5. Agency for Healthcare Research and Quality. Technology Assessment. Remote cardiac monitoring. 2007.
  6. Benditt DG, Nguyen JT. Syncope: Therapeutic Approaches J. Am. Coll. Cardiol. 2009;53;1741-1751
  7. Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). J Am Coll Cardiol 2003; 42:1493–531.
  8. Blue Cross Blue Shield Association. Medical Policy Reference Manual 2.02.08 – Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry, 05/16.
  9. Blue Cross Blue Shield Association. Medical Policy Reference Manual 2.02.24 – Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 05/16.
  10. Centers for Medicare and Medicaid Services (CMS) Manual System. Pub. 100-3. Medicare National Coverage, Chapter 1, Part 1, Section 20.15 NCD for Electrocardiographic (EKG) Services. 08/24/04.
  11. Centers for Medicare and Medicaid Services (CMS) Manual System. Pub. 100-3. Medicare National Coverage, Chapter 1, Part 1, Section 20.27 NCD for Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test. Last modified 04/23/09.
  12. ClinicalTrials.gov, CardioMEMS HF System Post Approval Study, sponsored by St. Jude Medical, accessed 07/26/16.
  13. Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Circulation. 1999; 100:886-893.
  14. ECRI. Custom Hotline Response. Mobile Cardiac Outpatient Telemetry for Detecting Arrhythmias; Updated 06/16/2010.
  15. ECRI Hotline Response Article. Implantable Loop Recorder for Diagnosis of Cardiac Arrhythmia as the Cause of Syncope; Updated 04/20/2009.
  16. ECRI Hotline Response Article. Mobile Cardiac Outpatient Telemetry for Detecting Arrhythmias; Updated 02/2013.
  17. First Coast Service Options, Inc, LCD for Noncovered Services (L33777), 07/16.
  18. Fuster V, Ryden LE, Cannonm DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2006;48;e149-e246.
  19. Hayes, Inc. Health Technology Brief. Mobile Cardiac Outpatient Telemetry (MCOT) for Home Monitoring of Cardiac Patients. Lansdale, PA: Hayes, Inc.; April 2008.
  20. Ho C. Implantaable hemodynamic monitoring (the Chronicle IHM system): remote telemonitoring for patients with heart failure. Issues Emerg Health Technol. 2008 Jan;(111):1-4. [PubMed ID18354860].
  21. Joshi AK, Kowey PR, Prystowsky EN, Benditt DG, Cannom DS, Pratt CM, McNamara A, Sangrigoli RM. First experience with a Mobile Cardiac Outpatient Telemetry (MCOT) system for the diagnosis and management of cardiac arrhythmia. Am J Cardiol. 2005 Apr 1; 95(7): 878-81.
  22. Kadish AH, Buxton AE, Kennedy HL, Knight BP, Mason JW, Schuger CD, Tracy CM. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography); J Am Coll Cardiol 2001; 38: 2091-100.
  23. Krahnke JS, et al. Heart failure and respiratory hospitalizations are reduced in patients with heart failure and chronic obstructive pulmonary disease with the use of an implantable pulmonary artery pressure monitoring device. J Cardiac Fail 2015;21(3):240-9.
  24. McKesson InterQual 2012 Procedures Criteria for Ambulatory Electrocardiography.
  25. Mehall JR, Kohut RM Jr, Schneeberger EW, Merrill WH, Wolf RK. Absence of correlation between symptoms and rhythm in "symptomatic" atrial fibrillation. Ann Thorac Surg. 2007 Jun; 83(6): 2118-21.
  26. Mortara A, Pinna GD, Johnson P, et al. Home telemonitoring in heart failure patients: the HHH study (Home or Hospital in Heart Failure). Eur J Heart Fail. 2009 mar;11(3):312-8 [PubMed ID 19228800].
  27. Moya A et al. Guidelines for the diagnosis and management of syncope. Eur Heart J 2009 Nov;30(21):2631-2671. European Society of Cardiology. Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology.
  28. Ng E, Stafford PJ, Ng GA. Arrhythmia detection by patient and auto-activation in implantable loop recorders. J Interv Card Electrophysiol. 2004 Apr; 10(2): 147-52.
  29. Olson JA, Fouts AM, Padanilam BJ, Prystowsky EN. Utility of mobile cardiac outpatient telemetry for the diagnosis of palpitations, presyncope, syncope, and the assessment of therapy efficacy. J Cardiovasc Electrophysiol. 2007 May; 18(5): 473-7. Epub 2007 Mar 6.
  30. Pinna GD, Maestri R, Andrews D, et al. Home telemonitoring of vital signs and cardiorespiratory signals in heart failure patients: system architecture and feasibility of the HHH model. Int J Cardiol. 2007 Sep 3; 120(3):371-9. [PubMed ID 17189654].
  31. Ponikowski P, et al, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016 May 20. doi: 10.1002/ejhf.592.
  32. Prystowsky EN. Assessment of rhythm and rate control in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2006 Sep; 17 Suppl 2:S7-S10.
  33. Raviele A et al. Management of patients with palpitations: A position paper from the European Heart Rhythm Association. Europace 2011 Jul;13(7):920-934.
  34. Rothman SA, Laughlin JC, Seltzer J, Walia JS, Baman RI, Siouffi SY, Sangrigoli RM, Kowey PR. The diagnosis of cardiac arrhythmias: a prospective multi-center randomized study comparing mobile cardiac outpatient telemetry versus standard loop event monitoring. J Cardiovasc Electrophysiol. 2007 Mar; 18(3): 241-7.
  35. Saarel EV, Doratotaj S, Sterba R. Initial experience with novel mobile cardiac outpatient telemetry for children and adolescents with suspected arrhythmia. Congenit Heart Dis. 2008 Jan;3(1):33-8 [PubMed ID 18373747].
  36. Strickberger SA, Benson DW, et al. AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and The Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation in Collaboration with the Heart Rhythm Society. J Am Coll Cardiol. 2006; 47; 473-484.
  37. Tayal AH, Tian M, Kelly KM, Jones SC, Wright CG, Singh D, Jarouse J, Brillman J, Murali S, Gupta R. Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology 2008 Nov 18;71(21):1696-701 [PubMed ID 18815386].
  38. Tsang JP, Mohan S, Benefits of monitoring patients with mobile cardiac telemetry (MCT) compared with the Event or Holter monitors, Med Devices (Auckl). 2013 Dec 9;7:1-5.
  39. US Food and Drug Administration. External Mobile Outpatient Cardiac Telemetry System: CardioNet Mobile Cardiac Outpatient Telemetry™ (MCOT™) Services 510(k) premarket approvals (K100155; K063222; K012241;K072558). Accessed 02/07/13.
  40. U.S. Food and Drug Administration (FDA). TZ Medical's Aera CT device 510(k) premarket approval (K102507), 06/13/11.
  41. U.S. Food and Drug Administration (FDA), Medical Devices- CardioMEMS HF System, 05/14; accessed at fda.gov 07/26/16.
  42. Vasamreddy CR, Dalal D, Dong J, Cheng A, Spragg D, Lamiy SZ, Meininger G, Henrikson CA, Marine JE, Berger R, Calkins H. Symptomatic and asymptomatic atrial fibrillation in patients undergoing radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 2006 Feb; 17(2): 134-9.
  43. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B,Fromer M, Gregoratos G, Klein G, Moss A, Myerburg R, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death; A Report of the American College of Cardiology/American heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 2006; 48: 247-346.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/16.

GUIDELINE UPDATE INFORMATION:

11/15/01

Medical Coverage Guideline Reformatted.

01/01/02

HCPCS coding changes.

01/01/03

HCPCS coding changes.

03/15/03

Reviewed; no changes.

03/15/04

Review and revision of guideline consisting of updating references, adding description and coverage criteria for implantable loop recorder, and converting MCG to “Guideline No Longer Scheduled For Routine Review”. Also changed the title to "Ambulatory Event Monitors".

04/01/06

HCPCS coding update consisting of the addition of S0345-S0347 and investigational statement for outpatient cardiac telemetry.

06/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

07/15/08

Review and revision of guideline consisting of updated references.

01/01/09

Annual HCPCS coding update: added codes 93228, 93229, 93285, 93291, 93298 and 93299. Revised codes 93268, 93270, 93271 and 93272. Deleted code 93727.

09/15/09

Scheduled review; no change to position statement; references updated.

01/01/10

Annual HCPCS coding update: revised descriptor for 93285; deleted S0345, S0346, and S0347.

08/15/10

Scheduled review; position statement unchanged; references updated.

01/01/11

Revision; Annual HCPCS coding update: revised descriptors for 93228, 93229, 93268, 93270, 93271, and 93272; related ICD-10 codes added; formatting changes.

08/15/11

Annual review; position statement unchanged; references updated; formatting changes.

09/15/11

Revision; formatting changes.

01/01/12

Annual HCPCS coding update: revised code descriptor for 93271.

03/15/11

Scheduled review; position statement unchanged; CPT codes 0295T – 0298T added; references updated.

09/01/12

Revision: updated billing and coding section to add coding instructions and remove deleted codes 93012 and 93014.

01/01/13

Annual HCPCS coding update: revised descriptors for 93228, 93229, 93268, 93272, 93285, 93291, and 93298.

03/15/13

Scheduled review; position statement unchanged; Program Exception added for Medicare Advantage products; references updated.

07/15/14

Scheduled review; position statement unchanged; Program Exception section updated; references updated.

09/15/15

Revision; guideline title, description section, position statement, program exception, and references updated; formatting changes.

11/01/15

Revision: ICD-9 Codes deleted.

09/15/16

Revision; description, position statements, coding/billing, and references updated; formatting changes.

Date Printed: June 23, 2017: 06:21 PM