ModifiedAmbetter NevadaPolicy CP.MP.113

Holter Monitors (up to 48 hours)

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.

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

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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

93224	External 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.
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; 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

G45.9	Transient cerebral ischemic attack, unspecified.
I42.0	Dilated cardiomyopathy.
I48.0	Atrial fibrillation and flutter (range I48.0 through I48.92 included).
R55	Syncope and collapse.
R42	Dizziness and giddiness.
Z95.0	Presence of cardiac pacemaker.
Z95.810	Presence 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