ModifiedAmbetter NevadaPolicy CP.MP.243

Implantable Loop Recorder

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This policy governs coverage of implantable loop recorders (ILRs), also called implantable cardiac monitors (ICMs), for detecting suspected or known cardiac arrhythmias. It applies to requests for initial implantation and replacement when specified clinical criteria are met.

Policy Summary

PayerAmbetter Nevada

PolicyImplantable Loop Recorder

Policy CodePolicy CP.MP.243

Change TypeModified

Effective DateN/A

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionObtain mandatory secondary medical director review for selected ILR/ICM requests before authorization.

SourceLink

POLICY UPDATE CHANGES

The January 2024 revision added criteria for requests for replacement implantable loop recorders.

ICD-10 codes were removed in the April 2023 revision.

The policy was reviewed in November 2025 and its references were updated.

30 daysExternal ambulatory monitoring period generally required before qualifying ILR requests

<1/monthExample symptom frequency threshold for infrequent symptoms

3HCPCS codes listed

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ModifiedAmbetter NevadaPolicy CP.MP.243

Implantable Loop Recorder

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Sign up for Ambetter Nevada Policy CP.MP.243 alerts

Get alerted when Policy CP.MP.243 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyImplantable Loop Recorder

Policy CodePolicy CP.MP.243

Change TypeModified

Effective DateN/A

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionObtain mandatory secondary medical director review for selected ILR/ICM requests before authorization.

SourceLink

POLICY UPDATE CHANGES

The January 2024 revision added criteria for requests for replacement implantable loop recorders.

ICD-10 codes were removed in the April 2023 revision.

The policy was reviewed in November 2025 and its references were updated.

30 daysExternal ambulatory monitoring period generally required before qualifying ILR requests

<1/monthExample symptom frequency threshold for infrequent symptoms

3HCPCS codes listed

Medical Necessity Criteria

Initial medically necessary indications

ILR/ICM is considered medically necessary when any one of the following indication groups is met.

Qualifying indications

Suspected silent atrial fibrillation after cryptogenic stroke: Suspected silent atrial fibrillation in the setting of cryptogenic stroke, with 30-day external ambulatory monitoring inconclusive or contraindicated.30-day external ambulatory monitoring
Suspected or known ventricular arrhythmia, with 30-day external ambulatory monitoring inconclusive or contraindicated.30-day external ambulatory monitoring
Structural or infiltrative heart disease
- High risk for arrhythmias.
  Examples include family history, symptoms, or anatomy of structural heart disease.
- 30-day external ambulatory monitoring, such as an external loop recorder, is inconclusive or contraindicated.30 days
Recurrent unexplained syncope or presyncope
- Cardiac arrhythmia is suspected and external ambulatory monitoring, such as a 30-day external loop recorder, is inconclusive or contraindicated.30-day external ambulatory monitoring
- Symptoms are infrequent.Less than once per month, for example

Indications requiring mandatory secondary medical director review

An ILR/ICM may be considered medically necessary only after mandatory secondary medical director review when all requirements below are met.

Secondary-review requirements

Presenting condition
- Single abrupt unexplained syncope: Single, abrupt episode of unexplained syncope without prodrome resulting in injury or trauma.
  Prodrome examples include a sense of warmth, dizziness, pallor, diaphoresis, abdominal pain, changes in vision, or nausea.
- Recurrent unexplained palpitations: Significant, recurrent, and unexplained palpitations.
Suspected serious arrhythmia: Serious cardiac arrhythmia is suspected.

Replacement of an existing ILR/ICM

Replacement of an ILR/ICM may be considered medically necessary when all applicable prior criteria are met and the additional replacement requirements below are satisfied.

Replacement requirements

Existing monitor no longer functioning: The existing implantable loop recorder or implantable cardiac monitor is no longer functioning.
Existing monitor outside warranty: The existing monitor is outside its warranty.
Example: the device is nearing the end of its battery life.

Billing and Coding

CPT 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.
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.

HCPCS 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.

HCPCS 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

External ambulatory monitoring

Monitoring requirement30-day external ambulatory monitoring

Qualifying resultInconclusive or contraindicated

ExampleExternal loop recorder

Symptom frequency

Symptom patternInfrequent symptoms

Example thresholdLess than once per month

Applicable presentation

Review and Authorization Requirements

Prior Authorization

Secondary Medical Director Review Required

An implantable loop recorder (ILR)/implantable cardiac monitor (ICM) may be considered medically necessary only after mandatory secondary medical director review when all listed criteria are met.

Presenting condition: a single, abrupt episode of unexplained syncope without prodrome that resulted in injury or trauma, or significant, recurrent, unexplained palpitations.
Serious cardiac arrhythmia is suspected.
30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated.
Symptoms are infrequent (e.g., less than once per month).

Clinical Background

An implantable loop recorder (ILR), also called an implantable cardiac monitor (ICM), is a subcutaneous device implanted in the left pectoral region to detect cardiac arrhythmias. It records events automatically according to programmed criteria or when activated by the patient, is MRI-conditional, and typically has a battery longevity of 2–4 years.

ILR/ICM monitoring is used when arrhythmia symptoms are intermittent and remain unexplained, particularly in selected patients with syncope, palpitations, ventricular arrhythmias, or cryptogenic stroke. The duration and type of monitoring should reflect symptom frequency: short-term ambulatory ECG monitoring may be followed by external loop recording, with an ILR considered when prolonged noninvasive monitoring is unrevealing or inconclusive. Extended monitoring is especially useful when symptoms occur infrequently, such as less than once per month, because a longer observation period may capture an otherwise intermittent arrhythmia.

Device Definitions

Implantable loop recorder (ILR)

Device typeSubcutaneous monitoring device for the detection of cardiac arrhythmias

Implantation locationLeft pectoral region

Event storageStores events automatically according to programmed criteria or when triggered by the patient

Implantable cardiac monitor (ICM)

Alternative termImplantable cardiac monitor (ICM) is an alternative term for an implantable loop recorder

Other terminologyAlso called an insertable cardiac monitor

Definition