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    v1.0.28
    OpenPayerPolicy UpdatesCardiologyAmbetter Nevada Holter Monitoring Coverage Update …
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    ModifiedAmbetter NevadaPolicy CP.MP.113

    Holter Monitors (up to 48 hours)

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    Medical necessity guidelines for ambulatory ECG Holter monitoring up to 48 hours for adult and pediatric members/enrollees; governs coverage criteria and coding implications for Ambetter Nevada (Centene-affiliated health plans).

    Policy Summary
    PayerAmbetter Nevada
    PolicyHolter Monitors (up to 48 hours)
    Policy CodePolicy CP.MP.113
    Change TypeCriteria revised and additions (device requirementadded indications)
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for CPT 93224–93227 and document an FDA-approved Holter device plus a supporting ICD-10 diagnosis that meets medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    Criteria I. and II. updated to specify a Food and Drug Administration (FDA) approved Holter monitor device and ages changed to ≥ 18 years for adults and < 18 years for pediatrics.

    Added criteria for evaluation of recurrent chronic heart failure when arrhythmia is suspected and possible arrhythmias post ablation procedures.

    Added baseline or periodic screening for those with adult congenital heart disease to adult criteria.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    24-48 hoursmonitoring duration covered by this policy
    2 age groupsdistinct adult and pediatric criteria sets
    4 CPT codesreferenced CPT codes
    multiple ICD-10 rangesdiagnosis codes listed

    Medical Necessity and Coverage Criteria

    Adult (≥18 years) Medical Necessity Criteria

    Covered when ANY of the following adult indications are present AND monitoring is for 24–48 hours using an FDA-approved device:

    Adult indications list: A. Evaluation of unexplained syncope, near-syncope, episodic dizziness, recurrent palpitations, episodic shortness of breath or chest pain; B. Evaluation of neurological events when transient atrial fibrillation or flutter is suspected; C. Evaluation of syncope, near-syncope, episodic dizziness, or palpitations in whom a probable non-arrhythmic cause has been identified but in whom symptoms persist despite treatment of this other cause; D. Evaluation of members/enrollees with cardiomyopathy (e.g., arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy), or a first-degree relative with ARVC or HCM; E. Evaluation of possible or documented prolonged QT syndromes; F. To screen for asymptomatic arrhythmia in members/enrollees with Brugada syndrome; G. Assessment of efficacy of medication for arrhythmia treatment when baseline arrhythmia frequency is reproducible and of sufficient frequency to permit analysis; H. Detection of proarrhythmic responses to antiarrhythmic therapy in members/enrollees at high risk; I. Assessment of the function of pacemakers or implantable cardioverter defibrillators (ICD) with frequent palpitations, syncope, or near-syncope, and to assist in programming of enhanced features; J. Evaluation of suspected pacemaker or ICD component failure or malfunction when device interrogation is inconclusive; K. Assessment of efficacy of adjunctive medications in members/enrollees receiving frequent ICD therapy; L. Assessment of suspected variant angina; M. Evaluation of recurrent chronic heart failure when arrhythmia is suspected; N. Evaluation of possible arrhythmias post ablation procedures; O. Baseline or periodic screening for those with adult congenital heart disease.

    Pediatric (<18 years) Medical Necessity Criteria

    Covered when ANY of the following pediatric indications are present AND monitoring is for 24–48 hours using an FDA-approved device:

    Pediatric indications list: A. Evaluation of syncope, near-syncope, or dizziness in those with identified cardiac disease, previously documented arrhythmia, or pacemaker dependency; B. Evaluation of syncope or near-syncope associated with exertion when cause is not established; C. Evaluation of unexplained syncope, near-syncope, or sustained palpitation with no overt clinical evidence of heart disease; D. Assessment of efficacy of medications for arrhythmia after initiation or during rapid growth; E. Patients with cardiomyopathy or a first-degree relative with arrhythmogenic right ventricular cardiomyopathy; F. Possible or documented prolonged QT syndromes; G. Palpitation in patient with prior congenital heart disease surgery and significant residual hemodynamic abnormalities; H. Evaluation of asymptomatic congenital complete AV block, non-paced; I. Evaluation of cardiac rhythm after transient AV block associated with heart surgery or catheter ablation; J. Evaluation of rate-responsive or physiological pacing function in symptomatic patients.

    Not Medically Necessary

    Not medically necessary: Holter monitoring for any other indication not included in this policy is not medically necessary because efficacy has not been established.

    Any clinical indication for Holter monitoring that is not explicitly listed in this policy is excluded and considered not medically necessary.

    State Medicaid coverage provisions take precedence over this clinical policy when they conflict. Providers must also review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Coverage Articles, and the Health Plan's administrative policies and procedures, since coverage decisions are subject to the terms, conditions, exclusions and limitations of the applicable coverage documents.

    Holter monitoring performed for indications that are not specified in Criteria I (adult) or Criteria II (pediatric) within this policy is considered not medically necessary.

    Procedure and Diagnosis Codes

    Covered CPT Codes (Holter up to 48 hours)CPTCovered
    93224External 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.
    93225External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection).
    93226External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report.
    93227External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional.
    ICD-10-CM Diagnosis Codes that Support Coverage Criteria (selected examples; full ranges listed in policy)ICD-10
    G45.9Transient cerebral ischemic attack, unspecified.
    I42.0Dilated cardiomyopathy.
    I48.0Atrial fibrillation and flutter (range I48.0 through I48.92 included).
    R55Syncope and collapse.
    R42Dizziness and giddiness.
    Z95.0Presence of cardiac pacemaker.
    Z95.810Presence of automatic (implantable) cardiac defibrillator.
    inv-09: Monitoring duration — 24-48 hours
    Monitoring duration24–48 hours
    Initial approach for daily/near-daily symptomsContinuous Holter monitoring for 24 to 48 hours is the most practical initial approach
    Device requirement (operational change)Monitoring must be performed using an FDA‑approved Holter device for covered orders

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required per payer processes for Holter monitoring services coded with CPT 93224–93227. Submit prior authorization requests according to Ambetter Nevada procedures before scheduling services to avoid denial or delay of payment.

    • Affected CPT codes: 93224, 93225, 93226, 93227
    • Obtain prior authorization from Ambetter Nevada per plan-specific rules
    • Authorization must support medical necessity as defined in this policy
    Note

    Check Health Plan and LCD/NCD Requirements

    Providers must verify Health Plan-specific coverage rules, prior authorization procedures, and whether Medicare Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs) apply to the requested service. Plan-level and LCD/NCD requirements may impose additional documentation or limitation rules.

    • Check Ambetter Nevada provider portal or call the plan for prior auth submission pathways and forms

    Clinical Background

    Ambulatory electrocardiographic monitoring (Holter) is a continuous external recording of cardiac electrical activity performed for 24–48 hours using an FDA‑approved device to correlate symptoms such as palpitations, syncope, dizziness, chest pain, dyspnea, or fatigue with arrhythmias, to evaluate antiarrhythmic therapy or device function, and to assess suspected arrhythmic contributors to cardiomyopathy or post‑procedural arrhythmias.

    Key Definitions

    inv-19: Holter monitoring — definition
    DefinitionContinuous external ambulatory electrocardiographic recording and storage for up to 48 hours with a self‑activated event marker for symptom correlation
    PurposeUsed to correlate symptoms (palpitations, syncope/near‑syncope, dizziness, shortness of breath, chest pain, episodic fatigue) with arrhythmias
    Typical analysis outcomeRecorded data are analyzed with event markers to determine if symptoms are related to arrhythmia (documented arrhythmia, symptoms without arrhythmia, arrhythmia without symptoms, or equivocal findings)
    inv-20: CPT 93224–93227 — definition
    Codes includedCPT 93224, 93225, 93226, 93227 — external ECG recording up to 48 hours
    93224 descriptionIncludes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
    Policy Summary
    PayerAmbetter Nevada
    PolicyHolter Monitors (up to 48 hours)
    Policy CodePolicy CP.MP.113
    Change TypeCriteria revised and additions (device requirementadded indications)
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for CPT 93224–93227 and document an FDA-approved Holter device plus a supporting ICD-10 diagnosis that meets medical necessity.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaProcedure and Diagnosis CodesProvider Requirements, Prior Authorization, and DocumentationClinical BackgroundKey Definitions
  1. Review applicable Medicare LCDs/NCDs when services involve Medicare members or when plan policy references them
    2. Note

    Coverage Decisions and Administration

    Coverage decisions and the administration of benefits are subject to the terms, conditions, exclusions and limitations of the member's coverage document and applicable state and federal requirements. This policy is a guide to medical necessity and does not guarantee payment.

    • Coverage is subject to the member's Evidence of Coverage/certificate of coverage and applicable contract language
    • Health Plan-level administrative policies and procedures may affect coverage and claims processing
    Documentation Required

    Required Documentation and Device

    Document the clinical indication and supporting diagnosis using appropriate ICD-10-CM codes listed in the policy. Ensure the ordered Holter device is FDA-approved for the intended duration of monitoring. Retain and provide clinical notes, test results, and device reports to support medical necessity upon request.

    • Include relevant ICD-10-CM diagnosis codes that support medical necessity on the authorization and claim
    • Specify device make/model and confirm FDA approval when requested
    • Maintain clinical documentation (history of symptoms, prior testing, treatment rationale, and monitoring duration) in the medical record
    Denial Risk

    Non-covered Indications and Provider Obligations

    Holter monitoring for indications not included in this policy is considered not medically necessary and may be denied. Providers should follow Health Plan coverage documents and state Medicaid manuals where applicable. Review Medicare NCDs/LCDs and plan-level guidance to ensure compliance.

    • Services outside policy indications may be denied as not medically necessary
    • Follow Ambetter Nevada coverage documents and state/federal requirements when applicable
    • Contact the plan for questions about marginal or uncommon indications prior to ordering
    93225 descriptionRecording (includes connection, recording, and disconnection) for up to 48 hours
    93226 descriptionScanning analysis with report for up to 48 hours
    93227 descriptionReview and interpretation by a physician or other qualified health care professional for up to 48 hours
    inv-21: LCD L34636 — definition/reference
    LCD referenceLocal Coverage Determination L34636: electrocardiographic (EKG or ECG) monitoring (Holter or real‑time monitoring)
    Source and accessCenters for Medicare & Medicaid Services (CMS) Web site; L34636 published Oct 1, 2015; revised Oct 28, 2021
    PurposeProvides Medicare local coverage guidance for Holter and real‑time ECG monitoring referenced in this clinical policy