Implantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria
Customize your policy alerts
Sign up for Arizona Complete Health Policy CP.MP.243 alerts
Get alerted when Policy CP.MP.243 changes without checking for updates manually.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Primary medically necessary indications
Covered when ANY of the following are met:
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):
Approval requires secondary medical director review before authorization.
Replacement device
Replacement may be considered medically necessary when ALL of the following are met:
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
| 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. |
| 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. |
Provider Requirements, Authorization, and Operational Notes
Prior Authorization Required
Prior authorization required to establish that the request meets the listed medical necessity criteria.
- Prior authorization required.
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.
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.
- Recommend short-term continuous monitoring (24 hours to 7 days) and/or intermittent external loop recording up to 30 days as clinically appropriate prior to ILR/ICM placement.
- Document when 30-day external ambulatory monitoring is inconclusive or contraindicated as required by the indication.
Documentation Requirement
Documentation must demonstrate that prior 30-day external ambulatory monitoring was inconclusive or is contraindicated when the indication requires it. For replacement requests, documentation should show the existing monitor is no longer functioning and is outside its warranty.
- Provide documentation of prior 30-day external ambulatory monitoring results or reasons it was contraindicated.
- For replacement requests, include evidence the device is non-functioning and out of warranty (e.g., battery depletion).
Policy Effective Date and Legal Compliance
Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state and federal requirements. This policy is effective as of the date determined by the Health Plan; if posting date differs from the effective date, legal/regulatory requirements govern.
- Coverage decisions subject to member's evidence of coverage, policy, contract, state and federal laws, and Health Plan administrative policies.
- This clinical policy is effective as of the date determined by the Health Plan; verify the Health Plan's effective date and applicable legal/regulatory provisions.
Denial Risks and Administrative Coverage Reminder
Requests for indications not listed as medically necessary may be denied. Replacement requests may be denied if the existing monitor is still functioning or within warranty.
- Denial risk if the requested indication is not one of the listed medically necessary indications.
- Denial risk for replacement if existing device remains functional or is within warranty.
Key Terms and Device Definitions
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.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.