ModifiedAmbetter NevadaPolicy CP.MP.113

Holter Monitors (ambulatory ECG up to 48 hours)

Medical necessity guidelines for FDA‑approved Holter monitoring up to 48 hours for adults and pediatric members, covering indications, device and age criteria, and coding references for Ambetter Nevada.

Policy Summary

PayerAmbetter Nevada

PolicyHolter Monitors (ambulatory ECG up to 48 hours)

Policy CodePolicy CP.MP.113

Change TypeMaterial updates to age/device criteria and added adult indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets one of the listed medical indications for 24–48 hour Holter monitoring.

SourceLink

POLICY UPDATE CHANGES

Criteria I. and II. were updated to specify an FDA approved Holter monitor device and age thresholds (I: ≥ 18 years; II: < 18 years).

Added criteria I.M. 'Evaluation of recurrent chronic heart failure when arrhythmia is suspected' and I.N. 'Evaluation of possible arrhythmias post ablation procedures'.

Age wording changed from '> 18 years old' to '≥ 18 years old' and from '≤ 18 years old' to '< 18 years old'.

New ICD-10 codes were added to policy ranges (e.g., additional I25.* codes).

4 CPT codesCPT codes

24–48hMonitoring duration

≥18 / <18Age criteria

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Multiple rangesICD-10 support

Coverage Criteria for Holter Monitoring (≤ 48 hours)

Adult (Initial) Coverage Criteria

Covered when ALL of the following are met:

Adult Holter monitoring coverage

Indications (any): One or more of: evaluation of unexplained syncope, near-syncope, episodic dizziness, recurrent palpitations, episodic shortness of breath or chest pain; evaluation of neurological events when transient atrial fibrillation or flutter is suspected; evaluation of syncope/near-syncope/episodic dizziness or palpitations when a probable non-arrhythmic cause has been identified but symptoms persist despite treatment; evaluation of members/enrollees with cardiomyopathy (e.g., ARVC, HCM, dilated cardiomyopathy) or a first-degree relative with ARVC or HCM; evaluation of possible or documented prolonged QT syndromes; screening for asymptomatic arrhythmia in members/enrollees with Brugada syndrome; assessment of efficacy of medication for arrhythmia treatment when baseline arrhythmia frequency is reproducible and sufficient to permit analysis; detection of proarrhythmic responses to antiarrhythmic therapy in high-risk members/enrollees; assessment of pacemaker or ICD function with frequent palpitations, syncope, or near-syncope and to assist in programming; evaluation of suspected pacemaker or ICD component failure or malfunction when device interrogation is inconclusive; assessment of efficacy of adjunctive medications in members/enrollees receiving frequent ICD therapy; assessment of suspected variant angina; evaluation of recurrent chronic heart failure when arrhythmia is suspected; evaluation of possible arrhythmias post ablation procedures; baseline or periodic screening for those with adult congenital heart disease
Items correspond to policy I.A through I.O

Operational notes: Prior authorization is required when billing covered CPT codes for external ambulatory ECG up to 48 hours; requests must document that the member meets one of the listed medical indications for monitoring.

See provider actions for documentation requirements

Pediatric (Initial) Coverage Criteria

Covered when ALL of the following are met:

Pediatric Holter monitoring coverage

Pediatric Indications (any): One or more of: evaluation of syncope, near-syncope, or dizziness in members/enrollees with identified cardiac disease, previously documented arrhythmia, or pacemaker dependency; evaluation of syncope or near-syncope associated with exertion when cause is not established; evaluation of unexplained syncope, near-syncope, or sustained palpitation when there is no overt clinical evidence of heart disease; assessment of efficacy of medications for arrhythmia following initiation of treatment or during rapid somatic growth; evaluation of patients with cardiomyopathy or a first-degree relative with arrhythmogenic right ventricular cardiomyopathy; evaluation of possible or documented prolonged QT syndromes; evaluation of palpitation in a member/enrollee with prior surgery for congenital heart disease and significant residual hemodynamic abnormalities; evaluation of asymptomatic congenital complete AV block (non-paced); evaluation of cardiac rhythm after transient AV block associated with heart surgery or catheter ablation; evaluation of rate-responsive or physiologic pacing function in symptomatic members/enrollees.
Items correspond to policy II.A through II.J

Operational notes: Prior authorization may be required per the Health Plan; clinical documentation should tie symptoms/events to the need for 24-48 hour ambulatory ECG monitoring to permit symptom–ECG correlation and assessment of therapy or device function.

During the most recent annual review the policy language was revised to clarify device and age wording and to remove a previous miscellaneous exclusion. Specifically, the prior statement in Criteria II regarding “efficacy not established for all other indications” was removed. Operational updates also included specification of an FDA‑approved Holter device and clarified age thresholds for adult and pediatric criteria (adult = ≥ 18 years; pediatric = < 18 years), and coding ranges were updated.

If there is any conflict between this clinical policy and applicable state Medicaid coverage provisions, the state Medicaid provisions govern. Providers should consult the relevant state Medicaid manual for specific coverage rules and ensure compliance with those requirements when treating Medicaid members/enrollees.

Inclusion or exclusion of CPT codes in this policy does not by itself guarantee coverage. Providers must supply supporting clinical documentation demonstrating that the requested service meets the medical necessity criteria described in this policy and should verify current professional coding guidance prior to claim submission.

Coding References

Covered CPT CodesCPTCovered

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 CriteriaICD-10

G45.9	Transient cerebral ischemic attack, unspecified.
G71.00-G71.09	Muscular dystrophy.
G99.0	Autonomic neuropathy in diseases classified elsewhere.
I20.0-I20.9	Angina pectoris.
I24.0-I24.9	Other acute ischemic heart diseases.
I25.10	Atherosclerotic heart disease of native coronary artery without angina pectoris.
I25.112	Atherosclerosic heart disease of native coronary artery with refractory angina pectoris.
I25.702	Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris.
I25.712	Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris.
I25.722	Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris.

1–10 of 50

1/5

Provider Responsibilities & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization may be required for Holter monitoring up to 48 hours. Verify benefit coverage and obtain any required pre-service authorization per the Health Plan's administrative policies before scheduling the service.

Prior authorization requirement varies by product — check member-specific benefits.
Obtain and document authorization number when required.

Note

Administrative & Coverage Verification

Follow the Health Plan's administrative policies for claims submission, billing, and pre-service verification. Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member's coverage documents.

Confirm member eligibility and benefits prior to service.
Ensure services align with the member's certificate, evidence of coverage, or contract.

Background

Ambulatory electrocardiogram (Holter) monitoring continuously records cardiac electrical activity over a period of 24–48 hours to evaluate suspected arrhythmias, correlate symptoms with ECG events, assess the efficacy of antiarrhythmic therapy, and evaluate pacemaker/ICD function. It is particularly useful when symptoms are intermittent and too infrequent for an in‑office ECG and can aid in diagnosing syncope, palpitations, dizziness, chest pain, and other rhythm‑related concerns.

Definitions and Key Terms

Holter monitoring (Ambulatory ECG)

DefinitionAmbulatory electrocardiogram (Holter) monitoring: continuous external ECG recording of cardiac electrical activity for diagnostic evaluation, correlation of symptoms with ECG events, assessment of antiarrhythmic therapy efficacy, and evaluation of pacemaker/ICD function over a 24–48 hour period.

Typical usesEvaluate unexplained daily or near-daily symptoms (eg, syncope, palpitations, dizziness), assess medication or device efficacy, and detect ischemic ST-segment changes or variant angina.

DurationMonitoring duration covered by this policy: 24–48 hours.

LimitationsProvides quantitative correlation of symptoms with ECG phenomena but has limitations as a therapeutic guide; ST-segment/repolarization changes may have nonischemic causes.

Relevant CPT codes — Holter monitoring up to 48 hours

CPT code range

Policy Summary

PayerAmbetter Nevada

PolicyHolter Monitors (ambulatory ECG up to 48 hours)

Policy CodePolicy CP.MP.113

Change TypeMaterial updates to age/device criteria and added adult indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets one of the listed medical indications for 24–48 hour Holter monitoring.

SourceLink

On This Page

See provider actions for specific documentation and administrative requirements

Documentation Required

Clinical Documentation to Support Medical Necessity

Clinical documentation must support the medical necessity of Holter monitoring (24–48 hours). Include symptom description, symptom frequency, prior testing and treatments, pertinent medical history, and rationale for choosing 24–48 hour Holter monitoring as the preferred initial monitoring strategy.

Documented symptoms (e.g., syncope, near‑syncope, palpitations, episodic dizziness, unexplained chest pain or shortness of breath).
Frequency and timing of symptoms demonstrating suitability for 24–48 hour monitoring (daily or near-daily symptoms).
Results of prior evaluations or tests (ECG, event monitors, device interrogations) and treatments tried.
Clinical rationale linking symptoms to suspected arrhythmia or device evaluation needs.

Note

Preferred Initial Monitoring

Continuous 24–48 hour Holter monitoring is the preferred initial monitoring approach for members with daily or near‑daily unexplained symptoms or when assessing medication or treatment efficacy. Choose the monitoring method based on symptom frequency and diagnostic need and document the clinical reasoning in the medical record.

Preferred initial approach for frequent unexplained symptoms: 24–48 hour Holter.
If symptoms are infrequent, consider alternative ambulatory monitoring modalities per clinical judgment and plan policy.

Billing Rule

Coding & Billing Caveat

Inclusion or exclusion of CPT codes in this policy does not guarantee coverage. Providers should reference current coding guidance and the member's plan for reimbursement rules.

Codes referenced for informational purposes only: 93224, 93225, 93226, 93227.
Verify up-to-date coding and billing instructions prior to claim submission.

Note

Provider Actions & Coverage Conditions

Coverage determinations are subject to the member's contract, applicable state Medicaid provisions (when relevant), and the Health Plan's administrative policies. Providers must follow those policies and ensure services are consistent with the member's coverage documents.

When state Medicaid rules conflict with this policy, state Medicaid provisions take precedence.
Providers remain responsible for exercising professional judgment and for documentation of medical necessity.

93224External electrocardiographic recording up to 48 hours; 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; recording (includes connection, recording, and disconnection).

93226External electrocardiographic recording up to 48 hours; scanning analysis with report.

93227External electrocardiographic recording up to 48 hours; review and interpretation by a physician or other qualified health care professional.

Health Plan definition and ownership

Definition of Health Plan'Health Plan' means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates.

Policy ownershipThis clinical policy is the property of the Health Plan and was developed by experienced/licensed health care professionals based on current standards and guidance.

Coverage decisionsCoverage decisions and administration of benefits are subject to the member's coverage documents, state and federal requirements, and Health Plan-level administrative policies and procedures.