CurrentArizona Complete HealthPolicy CP.MP.243

Implantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria

Medical necessity policy defining indications, review pathways, and replacement criteria for implantable loop recorders/implantable cardiac monitors for members of Arizona Complete Health (Centene-affiliated health plans). Affects ordering clinicians, implanting providers, and utilization reviewers.

Policy Summary

PayerArizona Complete Health

PolicyImplantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria

Policy CodePolicy CP.MP.243

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating required prior 30-day external ambulatory monitoring was inconclusive or contraindicated when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Major indication categories listed as directly covered

30-dayExternal ambulatory monitoring timeframe referenced

2-4 yrsTypical battery longevity

MultipleCPT/HCPCS codes listed

~7Clinical citations

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Medical Necessity and Coverage Criteria

Primary medically necessary indications

Covered when ANY of the following are met:

Primary indications: A. Suspected silent atrial fibrillation (AF) in the setting of cryptogenic stroke when 30-day external ambulatory monitoring is inconclusive or contraindicated.

Primary indications: B. Suspected or known ventricular arrhythmia when 30-day external ambulatory monitoring is inconclusive or contraindicated.

Primary indications: C. History of structural or infiltrative heart disease (e.g., valvular aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease) AND both of the following: 1. High risk for arrhythmias (e.g., family history, symptoms, anatomy of structural heart disease); 2. 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated.

Primary indications: D. Recurrent, unexplained syncope or presyncope AND both of the following: 1. Cardiac arrhythmia is suspected and external ambulatory monitoring (e.g., 30-day external loop recorder) is inconclusive or contraindicated; 2. Symptoms are infrequent (e.g., less than once per month).30-day monitoring; symptom frequency <1/month

Structured as A–D with subconditions for C and D.

Secondary review (may be considered after mandatory secondary medical director review)

May be considered medically necessary when ALL of the following are met (requires mandatory secondary medical director review):

Secondary review criteria: A. Presenting condition meets one of: (1) single, abrupt episode of unexplained syncope without prodrome resulting in injury/trauma; (2) significant, recurrent and unexplained palpitations.

Secondary review criteria: B. Serious cardiac arrhythmia is suspected.

Secondary review criteria: C. 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated.

Secondary review criteria: D. Symptoms are infrequent (e.g., less than once per month).

Approval requires secondary medical director review before authorization.

Replacement device

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

Replacement criteria: Existing monitor is no longer functioning and is outside its warranty (e.g., device nearing end of battery life).

Replacement criteria: Clinical indication continues to meet the applicable criteria (see Primary indications and Secondary review criteria).

Replacement requests require demonstration the device is nonfunctional and out of warranty.

The coding section of this policy provides CPT and HCPCS/G‑code references for informational purposes only and clarifies that code lists are not all‑inclusive. Inclusion or exclusion of a code in this policy does not guarantee coverage; providers must reference current professional coding guidance before submitting claims. See the coding table for specific procedure and remote‑monitoring codes (e.g., 33285, 33286, 93285, 93291, 93298) and their descriptive language.

Coverage determinations under this policy are subject to the member’s plan documents and applicable legal requirements. The policy is a guide to medical necessity and does not guarantee payment; administration of benefits is governed by the terms, conditions, exclusions and limitations of the coverage documents and by state and federal requirements. Providers should confirm plan‑specific exclusions, limits, and the applicable effective date when seeking authorization or submitting claims.

Prior authorization is required to establish that requests meet the medical necessity criteria described in this policy (indication, prior monitoring attempts or contraindications, symptom frequency thresholds, and replacement rationale). Coding information in this policy is informational only and does not supersede plan or coding guidance when determining coverage.

Billing and Code References

Referenced 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.
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-08: Symptom frequency threshold

Defined thresholdSymptoms occurring less than once per month

Policy useUsed to justify ILR over shorter-term or external monitoring when events are infrequent

Clinical workflow implicationIf symptoms <1/month, consider ILR after noninvasive monitoring is inconclusive or contraindicated

inv-09: Prior external monitoring duration

Required prior external monitoring30-day external ambulatory monitoring (e.g., external loop recorder) when used prior to ILR

PurposeDemonstrates that shorter-term or external monitoring was inconclusive or contraindicated before ILR placement

Provider Requirements, Authorization, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization required to establish that the request meets the listed medical necessity criteria.

Prior authorization required.

Note

Check Medicare Coverage Determinations

Providers should review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying this policy to ensure consistency with Medicare coverage rules.

Check CMS NCDs, LCDs, and Coverage Articles at http://www.cms.gov prior to applying this policy for Medicare members/enrollees.

Note

Noninvasive Ambulatory ECG Monitoring Recommendation

Short-term continuous ambulatory ECG monitoring and/or intermittent external loop recording up to 30 days is recommended when indicated; an implantable loop recorder is typically considered only when 30-day external ambulatory monitoring is inconclusive or contraindicated.

Key Terms and Device Definitions

inv-20: Implantable loop recorder (ILR) / implantable cardiac monitor (ICM)

Device definitionSubcutaneous monitoring device implanted in the left pectoral region for detection and storage of cardiac arrhythmias

FunctionStores automatically triggered events per programmed criteria or patient-activated events for long-term rhythm surveillance

MRI statusDevice is MRI-conditional

Battery longevityTypical battery life ranges between 2 to 4 years (manufacturer-dependent)

inv-21: Infrequent symptoms

Frequency definitionInfrequent symptoms defined as occurring less than once per month

Background and Clinical Context

An implantable loop recorder (ILR) or implantable cardiac monitor (ICM) is a subcutaneously implanted device, typically placed in the left pectoral region, that provides long‑term electrocardiographic monitoring. The device records automatically and can store patient‑triggered events for later review. ILRs are often MRI‑conditional and have typical battery longevity of approximately 2–4 years.

In clinical practice, ambulatory ECG monitoring is performed in a stepwise fashion starting with short‑term continuous monitoring or external loop recorders; an ILR is considered when symptoms are infrequent (e.g., less than once per month) or when noninvasive monitoring (commonly a 30‑day external ambulatory monitor) is inconclusive or contraindicated. ILRs increase diagnostic yield for conditions such as unexplained syncope and detection of silent atrial fibrillation after cryptogenic stroke, and they also support evaluation of suspected ventricular arrhythmias or high‑risk structural/infiltrative heart disease when prior monitoring is unrevealing.