CurrentAmbetter NevadaPolicy CP.MP.243

Implantable Loop Recorder (ILR/ICM) Coverage Criteria

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Medical necessity criteria and coding implications for implantable loop recorders (also called insertable/implantable cardiac monitors) used to detect cardiac arrhythmias for Ambetter Nevada members and providers requesting coverage.

Policy Summary

PayerAmbetter Nevada

PolicyImplantable Loop Recorder (ILR/ICM) Coverage Criteria

Policy CodePolicy CP.MP.243

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for ILR insertion or removal and document that 30-day external ambulatory monitoring was inconclusive or contraindicated when required by the criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentAmbetter NevadaPolicy CP.MP.243

Implantable Loop Recorder (ILR/ICM) Coverage Criteria

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Policy Summary

PayerAmbetter Nevada

PolicyImplantable Loop Recorder (ILR/ICM) Coverage Criteria

Policy CodePolicy CP.MP.243

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for ILR insertion or removal and document that 30-day external ambulatory monitoring was inconclusive or contraindicated when required by the criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medical Necessity and Coverage Criteria

Initial Medical Necessity Indications

Covered when ANY of the following are met:

Section I: A. Suspected silent atrial fibrillation (AF) in the setting of cryptogenic stroke, when 30-day external ambulatory monitoring is inconclusive or contraindicated;see individual nodes

Each lettered indication is sufficient on its own if conditions met

Section I: B. Suspected or known ventricular arrhythmia when 30-day external ambulatory monitoring is inconclusive or contraindicated;see individual nodes

Each lettered indication is sufficient on its own if conditions met

Section I: C. History of structural or infiltrative heart disease (e.g., valvular aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease) and BOTH 1) high risk for arrhythmias (e.g., family history, symptoms, anatomy of structural heart disease) and 2) 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated;see individual nodes

Each lettered indication is sufficient on its own if conditions met

Section I: D. Recurrent, unexplained syncope or presyncope and BOTH 1) cardiac arrhythmia is suspected and external ambulatory monitoring (e.g., 30-day external loop recorder) is inconclusive or contraindicated and 2) symptoms are infrequent (e.g., less than once per month).see individual nodes

Each lettered indication is sufficient on its own if conditions met

Secondary-review Indications

Covered when ALL of the following are met and secondary medical director review is completed:

Section II: A. Presenting condition is either 1) single, abrupt episode of unexplained syncope without prodrome resulting in injury/trauma OR 2) significant, recurrent and unexplained palpitations;all must be met

Requires mandatory secondary medical director review

Section II: B. Serious cardiac arrhythmia is suspected;all must be met

Requires mandatory secondary medical director review

Section II: C. 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated;all must be met

Replacement Devices

Replacement may be considered medically necessary when ALL of the following are met:

Section III: Existing monitor is no longer functioning and is outside its warranty (e.g., device is nearing the end of its battery life) AND the patient meets the applicable clinical criteria (Sections I or II).all must be met

Replacement requests evaluated under same clinical criteria

Services or codes not meeting the medical necessity criteria in Sections I–III are not supported by this clinical policy. CPT and HCPCS codes listed in the policy are provided for informational purposes only and inclusion or exclusion of any code does not guarantee coverage; providers must reference current coding guides and submit claims consistent with the member’s benefits and billing rules.

Coverage and payment determinations are governed by the member’s specific benefit documents. This clinical policy is a guide to medical necessity and does not constitute a contract or guarantee of payment; coverage is subject to all terms, conditions, exclusions, and limitations of the evidence of coverage or contract and to applicable state and federal requirements (including state Medicaid provisions, which take precedence when in conflict).

Use of an implantable loop recorder (ILR/ICM) is not supported when 30-day external ambulatory monitoring has not been attempted or is not documented as inconclusive or contraindicated. Per policy, ILR placement is considered when external ambulatory monitoring (for example, up to a 30-day external loop recorder) is unsuccessful or cannot be used; requests that do not document prior external monitoring or a contraindication/inconclusive result are at risk for denial.

Procedure, Monitoring, and Billing Codes

Referenced CPT/Monitoring CodesCPT

33285	Insertion, subcutaneous cardiac rhythm monitor, including programming.
33286	Removal, subcutaneous cardiac rhythm monitor.
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; subcutaneous cardiac rhythm monitor 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; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis.
93298	Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional.

Referenced HCPCS/G-codesHCPCS

C1764	Event recorder, cardiac (implantable).
E0616	Implantable cardiac event recorder with memory, activator, and programmer.
G2066	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results.

inv-09: Symptom frequency

Symptom frequency thresholdInfrequent events (e.g., less than once per month) favor use of an implantable loop recorder (ILR) when external ambulatory monitoring is inconclusive or contraindicated.

Guiding principleFrequency of symptoms should dictate the type of recording; longer-term monitoring is required for more infrequent events.

Clinical applicationFor recurrent, unexplained syncope/presyncope, ILR is appropriate when symptoms are infrequent (eg, < once per month) and external ambulatory monitoring (eg, 30-day) is inconclusive/contraindicated.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Provider Requirements, Authorization, and Documentation

Prior authorization is required for ILR/ICM insertion and removal. Requests must include documentation that supports the indication (for example, cryptogenic stroke with inconclusive 30-day external monitoring, suspected ventricular arrhythmia, history of structural/infiltrative heart disease with high arrhythmia risk, or recurrent unexplained syncope with infrequent symptoms) and demonstrate that 30-day external ambulatory monitoring was inconclusive or contraindicated when applicable. Providers should recommend and document a trial of longer-term external ambulatory monitoring (e.g., up to 30 days or external loop recorder) prior to ILR when clinically appropriate. Requests that do not meet the medical necessity criteria described in Sections I–III risk denial. Coverage determinations are subject to all terms, conditions, exclusions and limitations of the member's benefit plan, and claims/payment are governed by the plan contract. Providers must verify the clinical policy effective date and comply with any applicable legal or regulatory requirements, including provider notification timelines.

Prior authorization required for insertion and removal of ILR/ICM
Include supporting documentation: prior external monitoring results, contraindications to external monitoring, symptoms frequency, clinical rationale
Document trial of longer-term external ambulatory monitoring (e.g., up to 30 days) when appropriate
Requests not meeting Sections I–III medical necessity criteria may be denied
Coverage is subject to member benefit terms, exclusions, limitations, and contract provisions

Device Background and Clinical Context

An implantable loop recorder (also called an insertable or implantable cardiac monitor) is a subcutaneous cardiac rhythm monitoring device implanted typically in the left pectoral region that automatically and/or patient-activated records cardiac events for prolonged surveillance. Many ILR/ICM systems are MRI-conditional, and device battery longevity varies by manufacturer but is generally in the range of approximately 2–4 years depending on device and usage.

Key Definitions

inv-19: ILR/ICM definition

Device typeSubcutaneous cardiac rhythm monitoring device (also called insertable or implantable cardiac monitor).

Typical implantation siteLeft pectoral region (subcutaneous implantation).

Recording modesAutomatically records events per programmed criteria and can be patient-activated to store symptomatic episodes.

MRI status and longevityDevices are MRI-conditional; battery longevity typically ranges from approximately 2 to 4 years depending on manufacturer and model.

inv-20: Inconclusive 30-day external ambulatory monitoring

DefinitionExternal ambulatory ECG monitoring (eg, up to 30 days external loop recorder) that has failed to document a causative arrhythmia for the patient's symptoms or is contraindicated.