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CurrentBaylor Scott & White Health PlanPolicy 065

Cardiac Monitoring

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Clinical coverage criteria and coding guidance for outpatient cardiac monitoring services (external loop recorders, mobile cardiovascular telemetry, implantable loop recorders, CardioMEMS and related devices) for Baylor Scott & White Health Plan members.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyCardiac Monitoring

Policy CodePolicy 065

Change TypeNo material changes

Effective DateMar 1, 2026

Last ReviewFeb 26, 2026

Next Review DateFeb 26, 2027

Key ActionPrior authorization is not required for cardiac monitoring services covered by this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not requiredPrior authorization for covered services

30 daysTypical maximum wear period

WeeklyCardioMEMS monitoring frequency

NYHA IIICardioMEMS indication severity

41+References cited

Policy 065Policy identifier

Coverage Criteria for Outpatient Cardiac Monitoring

External intermittent cardiac event monitors (external loop recorders) — Medically Necessary

BSWHP may consider external intermittent cardiac event monitors medically necessary for ANY of the following conditions:

External loop recorder indications: A. To document a dysrhythmia instead of using a Holter monitor or if a Holter monitor fails to document a suspected dysrhythmia; OR B. To document the benefit after initiating drug therapy for a dysrhythmia; OR C. To document the recurrence of a dysrhythmia after discontinuation of drug therapy; OR D. To document the results after an ablation procedure for dysrhythmia; OR E. To evaluate syncope, palpitations and lightheadedness that are thought to be secondary to a cardiac dysrhythmia, AND all other methods have failed to illuminate the etiology.

External loop recorders are considered experimental and investigational for all other indications.

Mobile cardiovascular telemetry (MCT) — Medically Necessary

BSWHP may consider MCT medically necessary for the evaluation of:

MCT indications: A. Atrial fibrillation when prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the discontinuation of anticoagulation therapy; OR B. Recurrent unexplained episodes of pre-syncope, syncope, palpitations, or dizziness when ALL of the following are met: 1) A cardiac dysrhythmia is suspected as the cause of the symptoms AND 2) Members have a non-diagnostic Holter monitor, or symptoms occur infrequently (less frequently than daily) such that the dysrhythmia is unlikely to be diagnosed by short term monitoring; AND 3) All other methods have failed to illuminate the etiology.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyCardiac Monitoring

Policy CodePolicy 065

Change TypeNo material changes

Effective DateMar 1, 2026

Last ReviewFeb 26, 2026

Next Review DateFeb 26, 2027

Key ActionPrior authorization is not required for cardiac monitoring services covered by this policy.

SourceLink

On This Page

Implantable loop recorder — Medically Necessary

BSWHP may consider an implantable loop recorder medically necessary for evaluation of recurrent unexplained episodes when ALL of the following criteria are met:

Implantable loop recorder criteria: A. A cardiac dysrhythmia is suspected as the cause of the symptoms; AND B. Non-invasive ambulatory monitoring, consisting of either MCT or two 30-day external loop recordings, fails to establish a definitive diagnosis because the symptoms occur so infrequently and unpredictably that the monitoring period may not have been long enough to capture a diagnostic ECG; AND C. All other methods have failed to illuminate the etiology.

Implantable loop recorders are considered experimental and investigational for all other indications.

CardioMEMS implantable congestive heart failure monitor — Medically Necessary

BSWHP may consider the CardioMEMS implantable congestive heart failure monitor medically necessary when the following criteria are met:

CardioMEMS criteria: A. Diagnosis of New York Heart Association (NYHA) Class III heart failure symptoms persistent despite maximally tolerated medical and device therapies; AND B. At least one heart-failure related hospitalization within the previous 12 months; AND C. Able to take dual antiplatelet or anticoagulants for one-month post-implant; AND D. Age >= 18 years; AND E. Diagnosis of heart failure for at least three months (either preserved or reduced LVEF); AND F. PA branch diameter sized between 7 and 15 mm; AND G. BMI ≤ 35 (if BMI > 35, chest circumference at axillary level required and do not implant if chest circumference > 165 cm); AND H. Monitoring must occur at least once weekly.PA branch diameter 7-15 mm; BMI ≤ 35; monitoring >= weekly

All other implantable congestive heart failure monitors are considered experimental and investigational.

Coding and Device Parameters

Covered CPT CodesCPTCovered

33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days
33282	Implantation of cardiac event monitor
33285	Insertion, subcutaneous cardiac rhythm monitor, including programming
33286	Removal, subcutaneous cardiac rhythm monitor
93224	External recording up to 48h with interpretation
93225	Ext recording up to 48h
93226	Ext recording up to 48h with report
93227	Ext recording up to 48h with report and interpretation
93228	Ext remote cardiac telemetry up to 30 days

1–10 of 27

1/3

HCPCS CodesHCPCSCovered

C1764	Implantable cardiac event recorder
E0616	Implantable cardiac event monitor with memory, etc.
C2624	Implantable wireless pulmonary artery pressure sensor

Potentially applicable ICD-10 CodesICD-10

G45.9	TIA
I25.82	Complete Coronary Occlusion
I44.0 - I49.9	Arrhythmias
R00.0 - R00.9	Tachy/brady
R42	Giddiness and dizziness
R55	Syncope and Collapse
Z86.73 - Z86.74	TIA/Sudden cardiac arrest, resuscitated

CardioMEMS PA branch diameter — device parameter

PA branch diameter range7 - 15 mm

Role in eligibilityPA branch diameter sized between 7 and 15 mm is required for CardioMEMS implantation

Imaging noteMeasurement range is generally not reported in imaging studies prior to the procedure

CardioMEMS BMI and chest circumference implant guidance

BMI threshold for implantBMI ≤ 35

If BMI > 35Chest circumference at axillary level is required

Absolute chest circumference limitDo not implant if chest circumference > 165 cm due to poor signal strength

Provider Actions, Authorization, and Documentation

Documentation Required

Provider Actions — Authorization & Documentation

Prior authorization is not required for cardiac monitoring services covered by this policy. Clinical documentation should demonstrate that criteria for the selected monitoring modality are met (e.g., suspected cardiac dysrhythmia, symptom correlation).

Prior authorization: Not required for cardiac monitoring per policy header (See Evidence of Coverage/SPD for plan-specific rules).
Clinical justification: Document suspected cardiac dysrhythmia and symptom correlation; include prior short-term monitoring results (e.g., non-diagnostic Holter) when applicable.

Prior Authorization

Non‑invasive Monitoring Attempted Before Implantable

An implantable loop recorder (ILR) is considered medically necessary only after non-invasive ambulatory monitoring has been attempted and failed to establish a diagnosis. Non-invasive ambulatory monitoring acceptable for this step includes either mobile cardiovascular telemetry (MCT) or two 30-day external loop recordings. The requirement is intended for patients with infrequent, unpredictable symptoms where shorter monitoring failed to capture diagnostic ECG correlates.

Required prior attempt: MCT (e.g., Ziopatch®, CardioNet/MCOT) OR two separate 30-day external loop recorder trials.
Indication context: For recurrent unexplained pre-syncope, syncope, palpitations, or dizziness when a cardiac dysrhythmia is suspected and other methods have failed.

Note

Supporting References

Supporting references that informed this policy are listed and maintained for review. Key references include randomized trials, systematic reviews, device studies, and clinical guidelines relevant to ambulatory cardiac monitoring and implantable and implantable hemodynamic devices. The policy is periodically updated as new evidence becomes available.

Representative citations: de Lusignan et al. (1999, 2001); Cordisco et al. (1999); TEN‑HMS investigators (Cleland et al.); COMPASS‑HF (Bourge et al.); CardioMEMS evidence and HTA reports (ICER, NICE, Hayes); ESC and UpToDate syncope/palpitations guidance.
Policy maintenance: Send additional clinical studies to the Medical Coverage Policy Committee (MCPC) and Quality Improvement Committee (QIC) for review.

Definitions and Device Descriptions

Mobile cardiovascular telemetry (MCT) — Noninvasive ambulatory cardiac event monitors

DefinitionNoninvasive ambulatory cardiac event monitors with extended memory capable of continuous measurement of heart rate and rhythm over several days and transmission of results to a remote monitoring center

FunctionContinuous measurement with real-time or near-real-time transmission to a monitoring center similar to inpatient telemetry

Typical wear periodDesigned for extended ambulatory monitoring over several days (background notes reference up to 30 days for external event monitors)

CardioMEMS (CM-IHM) — An implantable pulmonary artery pressure sensor

DefinitionAn implantable pulmonary artery pressure (PAP) sensor that allows patients to obtain remote daily PAP measurements to guide heart failure management

Patient instructionsPatients are instructed to obtain daily PAP readings which are automatically uploaded to a database accessible by clinicians

Clinical usePAP data are incorporated into heart failure treatment plans and can result in data-based adjustments to guideline-directed therapy

Implantable hemodynamic monitor / CardioMEMS — device category

ScopeImplantable pulmonary artery pressure sensors and other implantable hemodynamic monitors used for ambulatory monitoring of heart failure patients

Evidence summaryMeta-analysis and multiple studies cited indicate reduced hospitalizations with implantable hemodynamic monitors and supportive guidance from NICE and professional societies

Monitoring cadenceCardioMEMS monitoring typically involves daily patient measurements uploaded for clinician review; policy requires at least weekly monitoring for eligibility context