CurrentArizona Complete HealthPolicy CP.MP.113

Holter Monitors (PDF)

Medical necessity guidelines for FDA-approved Holter monitoring up to 48 hours for adult (≥18) and pediatric (<18) members/enrollees, listing indications supporting coverage and referenced CPT/ICD-10 codes. Notes that monitoring beyond 48 hours is governed by separate clinical decision support criteria.

Policy Summary

PayerArizona Complete Health

PolicyHolter Monitors (PDF)

Policy CodePolicy CP.MP.113

Change TypeRevisions/clarifications (age thresholds, FDA device requirement, ICD-10 additions)

Effective Date

Next Review Date

Key ActionProviders must document patient age, that the device is FDA-approved, and the specific covered indication from the policy to support medical necessity for Holter monitoring up to 48 hours.

SourceLink

POLICY UPDATE CHANGES

Criteria I updated to specify FDA-approved Holter device and age changed to ≥ 18 years; Criteria I.D updated to include ARVC, HCM, dilated cardiomyopathy, or a first-degree relative with HCM; Criteria I.O added for baseline or periodic screening for adult congenital heart disease; Criteria II age changed to < 18 years and specified FDA-approved device.

Added new ICD-10 codes I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, and I25.792 to policy.

Removed pediatric criteria II regarding efficacy not established for all other indications.

Policy provides medical necessity guidelines for Holter monitoring up to 48 hours; monitoring beyond 48 hours directed to separate clinical decision support criteria.

2Age cohorts specified (adult, pediatric)

CPT codes referenced

1Max monitoring duration covered (days)

~60ICD-10 codes listed (approx.)

Coverage Summary

Scope: Medical necessity guidelines for FDA-approved Holter monitoring up to 48 hours for adult (≥18) and pediatric (<18) members/enrollees, listing indications supporting coverage and referenced CPT and ICD-10 codes. Monitoring beyond 48 hours is governed by separate clinical decision support criteria.

Overview: This policy addresses ambulatory Holter monitoring (continuous external ECG recording for 24–48 hours) and defines coverage as covered with criteria; it specifies two age cohorts — adults (≥18 years) and pediatrics (<18 years) — with distinct medically necessary indications and requires use of an FDA-approved Holter device. Monitoring longer than 48 hours is excluded from these criteria and directed to separate criteria.

Key policy facts

Policy subjectHolter Monitors (ambulatory ECG up to 48 hours)

Policy numberCP.MP.113

StatusCURRENT

Last review date2025-09-25

Age cohorts specified2 (adult ≥18, pediatric <18)

CPT codes referenced93224, 93225, 93226, 93227 (4 codes)

Max monitoring duration covered1 day (policy covers up to 48 hours)

Approx. ICD-10 codes~60 (multiple ICD-10-CM codes listed to support coverage)

Medical Necessity Criteria (by age cohort)

Adult (≥ 18 years) — Medically Necessary Criteria

Holter monitoring up to 48 hours with an FDA-approved device is medically necessary when ALL of the following apply and ANY of the listed indications are present:

ALL of the following

ALL of the following
- Patient is a member/enrollee ≥ 18 years old
- Device is Food and Drug Administration (FDA) approved
- One of the following indications
  - Evaluation of unexplained syncope, near-syncope, episodic dizziness, recurrent palpitations, episodic shortness of breath or chest pain

Coding (CPT and ICD-10)

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 CriteriaICD-10Covered

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.
I24.81	Included in updated ranges per revision log.
I24.89	Included in updated ranges per revision log.
I25.10	Atherosclerotic heart disease of native coronary artery without angina pectoris.
I25.112	Atherosclerotic heart disease of native coronary artery with refractory angina pectoris.
I25.702	Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris.

1–10 of 52

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What Providers Must Do

Documentation Required

Indication documentation for medical necessity

Document patient age, that the Holter device is FDA-approved, and the specific covered indication from the policy to support medical necessity for Holter monitoring up to 48 hours.

Record patient age (adult ≥ 18 years or pediatric < 18 years).
Document that the device is Food and Drug Administration (FDA) approved.
Specify which covered indication from the policy criteria is present (cite relevant indication).

Billing Rule

Use CPT codes for up to 48-hour Holter monitoring

Report the appropriate CPT code(s) corresponding to recording, analysis, and/or interpretation for up to 48 hours of continuous external ECG monitoring.

Background & Evidence

Background: Ambulatory ECG (Holter) monitors continuously record cardiac electrical activity for a period of 24 to 48 hours to evaluate and diagnose arrhythmias or conduction abnormalities, correlate symptoms with ECG findings using event markers, assess efficacy of antiarrhythmic therapy, and evaluate pacemaker/ICD function and possible device malfunction. In pediatrics, Holter monitoring is used similarly and additionally for growth-related medication dose assessment, post-surgical surveillance for late arrhythmias after congenital heart surgery, and evaluation of conditions such as cardiomyopathies and prolonged QT syndromes.

Evidence: Guideline and expert sources supporting the policy include ACC/AHA/HRS guidelines (e.g., syncope, bradycardia/conduction, ventricular arrhythmia prevention), the 2017 ISHNE-HRS expert consensus on ambulatory ECG and external cardiac monitoring, AHA/ACC guidelines for hypertrophic cardiomyopathy, and UpToDate reviews — all cited as informing the indications and use of ambulatory Holter monitoring up to 48 hours.

Definitions

Holter monitoringContinuous external ambulatory electrocardiographic recording and storage for up to 48 hours using an FDA-approved device.

Relevant Medicare LCDs / Determinations

Name	Number	Effective (date)
Electrocardiographic (EKG or ECG) monitoring (Holter or real-time monitoring)	L34636	2015-10-01 (revised 2023-10-01)

Revision History

09/25revisionLatest

Annual review. Coding and descriptions reviewed; references updated; reviewed by external specialist. (Date of Last Revision: 09/25)

09/24removed

Annual review removed pediatric criteria II regarding 'efficacy not established for all other indications' and added new codes to existing ranges including I24.81 and I24.89.

09/23revised

Annual review (minor). Criteria I updated to specify an FDA‑approved Holter device and age changed to ≥ 18 years; Criteria I.D updated to include ARVC, HCM, dilated cardiomyopathy, or a first‑degree relative with HCM; Criteria I.O added for baseline or periodic screening for adult congenital heart disease; Criteria II updated to specify an FDA‑approved device and age changed to < 18 years.

Policy Summary

PayerArizona Complete Health

PolicyHolter Monitors (PDF)

Policy CodePolicy CP.MP.113

Change TypeRevisions/clarifications (age thresholds, FDA device requirement, ICD-10 additions)

Effective Date

Next Review Date

Key ActionProviders must document patient age, that the device is FDA-approved, and the specific covered indication from the policy to support medical necessity for Holter monitoring up to 48 hours.

SourceLink

On This Page

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 of that cause

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

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 of sufficient frequency to permit analysis

Detection of proarrhythmic responses to antiarrhythmic therapy in members/enrollees at high risk

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

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

Pediatric (< 18 years) — Medically Necessary Criteria

Holter monitoring up to 48 hours with an FDA-approved device is medically necessary when ALL of the following apply and ANY of the listed indications are present:

ALL of the following

Patient is a member/enrollee < 18 years old
Device is Food and Drug Administration (FDA) approved
One of the following indications
- 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 atrioventricular (AV) block, non-paced
- Evaluation of cardiac rhythm after transient AV block associated with heart surgery or catheter ablation
- Evaluation of rate-responsive or physiological pacing function in symptomatic members/enrollees

93224
93225
93226
93227

Documentation Required

Use supporting ICD-10 diagnosis codes

Use one of the listed ICD-10-CM diagnosis codes that supports the clinical indication when submitting claims to justify coverage for Holter monitoring up to 48 hours.

04/23added

Added new ICD‑10 codes I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, and I25.792 to the policy.

09/22added

Annual review (minor). Added criteria I.M 'Evaluation of recurrent chronic heart failure, when arrhythmia is suspected' and I.N 'Evaluation of possible arrhythmias post ablation procedures' (log notes additions).

clarification

Policy provides medical necessity guidelines for Holter monitoring up to 48 hours; monitoring beyond 48 hours is directed to separate clinical decision support criteria.