CurrentBaylor Scott & White Health PlanPolicy 065

MEDICAL COVERAGE POLICY SERVICE: Cardiac Monitoring

Defines medical necessity and coverage criteria for outpatient cardiac monitoring modalities (external loop recorders, mobile cardiovascular telemetry/MCT including Ziopatch, implantable loop recorders, CardioMEMS implantable PAP sensor) and other monitoring devices; lists devices considered experimental/investigational and durable medical equipment coverage positions. Applies to all lines of business unless overridden by Medicare/Medicaid NCD/LCD or plan documents.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMEDICAL COVERAGE POLICY SERVICE: Cardiac Monitoring

Policy CodePolicy 065

Change TypeReferences added; CardioMEMS criteria previously added

Effective Date03/01/2026

Next Review Date02/26/2027

Key ActionDocument prior non-diagnostic Holter or non-invasive ambulatory monitoring (MCT or two 30-day external loop recordings) and that all other methods have failed to establish etiology.

SourceLink

POLICY UPDATE CHANGES

Added additional references during 02/26/2026 review.

02/23/2023 update added criteria for CardioMEMS device.

5Covered device/monitor categories

8+CPT/HCPCS codes listed

9Experimental devices listed

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Scope: This policy defines medical necessity and coverage criteria for outpatient cardiac monitoring modalities including external loop recorders, mobile cardiovascular telemetry (MCT) / Ziopatch, implantable loop recorders (ILR), the CardioMEMS implantable pulmonary artery pressure (PAP) sensor, pacemaker monitors and related devices, and positions on devices considered experimental/investigational.

Subject: Cardiac Monitoring (Outpatient mobile monitors, external/implantable loop recorders, CardioMEMS, pacemaker monitors, BP monitors).

Status: CURRENT. Effective date: 03/01/2026, last review: 02/26/2026, next review: 02/26/2027.

Coverage stance: Mixed — the policy provides medical necessity criteria and covered codes for specified external and implantable monitoring devices while designating other devices and indications as experimental/investigational and not covered; applicability is to all lines of business unless superseded by applicable Medicare/Medicaid NCD/LCD or specific plan documents.

CardioMEMS thresholds and policy dates

PA branch diameter7-15 mm

Minimum age>= 18 years

Heart failure duration requirement>= 3 months (HF diagnosis)

BMI / chest circumference ruleBMI <= 35; if BMI > 35 measure chest circumference at axillary level; do not implant if chest circumference > 165 cm

Monitoring frequencyAt least once weekly

Policy effective date03/01/2026

Last review date02/26/2026

Next review date02/26/2027

Medical Necessity Criteria (by device/category)

External intermittent cardiac event monitors (external loop recorders)

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

ANY of the following

To document a dysrhythmia instead of using a Holter monitor or if a Holter monitor fails to document a suspected dysrhythmia
To document the benefit after initiating drug therapy for a dysrhythmia
To document the recurrence of a dysrhythmia after discontinuation of drug therapy
To document the results after an ablation procedure for dysrhythmia
Evaluate syncope/palpitations/lightheadedness
- To evaluate syncope, palpitations and lightheadedness that are thought to be secondary to a cardiac dysrhythmia
- All other methods have failed to illuminate the etiology

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Mobile cardiovascular telemetry (MCT) / Ziopatch / MCOT

BSWHP may consider MCT medically necessary for the evaluation of:

ANY of the following

Atrial fibrillation when prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the discontinuation of anticoagulation therapy
Recurrent unexplained pre-syncope/syncope/palpitations/dizziness
- A cardiac dysrhythmia is suspected as the cause of the symptoms
- 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
- All other methods have failed to illuminate the etiology

Implantable loop recorder (ILR)

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

ALL of the following

A cardiac dysrhythmia is suspected as the cause of the symptoms
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
All other methods have failed to illuminate the etiology

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CardioMEMS implantable congestive heart failure monitor (CM-IHM)

BSWHP may consider CardioMEMS medically necessary when ALL criteria are met:

ALL of the following

Diagnosis of New York Heart Association (NYHA) III heart failure symptoms persistent despite maximally tolerated medical and device therapies
At least one heart-failure related hospitalization within the previous 12 months
Able to take dual antiplatelet or anticoagulants for one-month post-implant
Greater than or equal to 18 years of age>= 18
Member has diagnosis of heart failure for at least three months, with either preserved or reduced left ventricular ejection fraction

Pacemaker monitors and trans-telephonic monitoring

BSWHP may consider self-contained pacemaker monitors and specialized telephone attachments medically necessary for members with cardiac pacemakers:

ANY of the following

Audible/visible signal pacemaker monitors that indicate pacemaker rate
Digital electronic pacemaker monitors that provide instantaneous digital readout of pacemaker pulse rate
Specialized telephone attachment for trans-telephonic transmission of pacemaker monitoring results (example: Pace Trac)

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Excluded, Experimental & Investigational Devices/Indications

Excluded / Experimental & Investigational

Devices and indications considered experimental and investigational or not covered:

ANY of the following

External loop recorders considered experimental and investigational for all indications other than those listed in external monitor criteria
Implantable loop recorders considered experimental and investigational for all indications other than those listed
CardioMEMS: all other implantable congestive heart failure monitors (e.g., Chronicle IHM System, HF System, HeartPOD System, Promote LAP System) are experimental and investigational and unproven
Specific devices considered experimental/investigational: Biotronik BioMonitor; Kardia Mobile (AliveCor); BodyGuardian Remote Monitoring System; iHEART; ViSi Mobile Monitoring System; CardioPatch
Pulse tachometers not covered as DME: Pulse tachometers (examples: Exersentry, Insta-Pulse, MacLevy Omni Pulse)
Automated oscillometer BP monitors experimental/investigational: Automated oscillometer blood pressure monitors for home use (e.g., Dinamap, Omron, BpTRU) are considered experimental and investigational
Home BP monitors/stethoscopes DME exception: Home blood pressure monitors and stethoscopes are not covered as DME except for members receiving hemodialysis or peritoneal dialysis in the home

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Denial Risk

Denial risk: experimental / investigational devices and indications

Claims for devices and indications listed as experimental/investigational or not covered are at risk for denial. Examples specifically identified include Biotronik BioMonitor; Kardia Mobile (AliveCor); BodyGuardian Remote Monitoring System; CardioPatch; pulse tachometers (e.g., Exersentry, Insta-Pulse, MacLevy Omni Pulse); and automated oscillometric home blood pressure monitors (e.g., Dinamap, Omron, BpTRU).

Coding (CPT / ICD-10 / HCPCS groups)

Covered / applicable CPT codes (may apply when criteria met)CPTCovered

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	External recording up to 48h
93226	External recording up to 48h with report
93227	External recording up to 48h with report and interpretation
93228	External remote cardiac telemetry up to 30 days

1–10 of 27

1/3

Applicable ICD-10 diagnosis codes (examples)ICD-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

HCPCS / DME / device codesHCPCSCovered

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

Codes listed in the policy apply only when the documented medical necessity criteria are met for the relevant monitoring modality.

Prior authorization is not required for cardiac monitoring services per the policy header, but providers must document required eligibility and prior non-diagnostic testing where specified (e.g., prior Holter or MCT attempts for ILR; CardioMEMS eligibility elements).

Provider Actions & Documentation Requirements

Documentation Required

Document prior monitoring attempts

For implantable loop recorder and external/MCT indications, document prior monitoring attempts before implanting or approving an ILR.

Prior non-diagnostic Holter monitor OR
Non-invasive ambulatory monitoring: MCT OR two 30-day external loop recordings
Documentation that all other methods have failed to establish the etiology

Documentation Required

CardioMEMS eligibility documentation

Document CardioMEMS eligibility elements per policy when requesting implant or monitoring.

NYHA class III heart failure despite maximally tolerated medical/device therapy
At least one heart-failure–related hospitalization within the prior 12 months
Able to take dual antiplatelet therapy (DAPT) or anticoagulant for one month post‑implant
Heart failure diagnosis duration ≥ 3 months
PA branch diameter 7–15 mm
BMI ≤ 35; if BMI > 35 then measure chest circumference at axillary level; do not implant if chest circumference > 165 cm
Plan for monitoring at least once weekly
Relevant codes: CPT 33289, CPT 93264, HCPCS C2624

Billing Rule

Prior authorization not required

Prior authorization is not required for cardiac monitoring services under this policy header.

Denial Risk

Denial risk: experimental / not covered devices and indications

Claims for the listed experimental/not covered devices and indications are at risk for denial. Examples called out in the policy include Biotronik BioMonitor; Kardia Mobile (AliveCor); BodyGuardian Remote Monitoring System; iHEART; ViSi Mobile Monitoring System; CardioPatch; pulse tachometers (Exersentry, Insta‑Pulse, MacLevy Omni Pulse); and automated oscillometric home BP monitors (Dinamap, Omron, BpTRU).

Documentation Required

Home BP monitor/stethoscope coverage exception (home dialysis)

Home blood pressure monitors and stethoscopes are not covered as durable medical equipment except when the member receives hemodialysis or peritoneal dialysis in the home. Document home dialysis to support coverage.

Confirm and document that member receives hemodialysis OR peritoneal dialysis in the home to qualify for DME coverage of home BP monitor or stethoscope.

Background, Evidence Summary & Definitions

Background: Cardiac event monitors are small portable devices worn during normal activity (up to 30 days) to record and store ECG segments initiated by the patient to capture infrequent dysrhythmias not detected on routine ECG or 24-hour Holter monitoring.

Mobile cardiovascular telemetry (MCT) refers to noninvasive ambulatory cardiac event monitors with extended memory that continuously measure heart rate and rhythm for several days and transmit results to a remote monitoring center; MCT is analogous to inpatient telemetry.

Non-invasive telemonitoring for congestive heart failure involves remote transmission of weight, blood pressure, heart rate and rhythm to a monitoring center; randomized trials (e.g., TEN-HMS) have shown mixed results for improved outcomes with telemonitoring versus usual care or nurse telephone support.

Invasive HF monitoring: CardioMEMS is an implantable pulmonary artery pressure (PAP) sensor system enabling remote PAP measurement to guide HF therapy. A meta-analysis (Thakker et al., 2021) found CardioMEMS was associated with reduced hospitalizations, and NICE IPG711 (2021) considered the evidence adequate to support percutaneously implanted PAP sensors for chronic HF management. ESC guidance (2021) notes PAP monitoring with a wireless system may be considered to improve clinical outcomes (Class IIb, Level B).

Evidence summaries: An AHRQ systematic review (ECRI EPC) concluded realtime continuous attended monitoring (single multicenter RCT) led to changes in disease management versus certain external loop recorders but overall evidence strength was rated weak; the CardioMEMS evidence base includes RCTs and meta-analyses and is supported by national guidance documents.

Source	Summary
AHRQ systematic review (ECRI EPC)
This AHRQ review (ECRI EPC) concluded realtime continuous attended monitoring led to changes in disease management versus certain external loop recorders based on a single high-quality multicenter study; strength of evidence described as weak and limited applicability to ELRs with automatic event activation.
Meta-analysis (Thakker et al. 2021)
Thakker et al. (2021) meta-analysis concluded patients with CardioMEMS (implantable pulmonary artery pressure monitoring) had reduced likelihood of hospitalizations compared with patients without CM-IHM.
NICE IPG711 (2021)
NICE Interventional Procedures Guidance IPG711 (2021) found the evidence base adequate to support use of percutaneously implanted pulmonary artery pressure sensors for managing chronic heart failure based on data from 9 studies.

Definitions:

• MCT — Mobile cardiovascular telemetry: noninvasive ambulatory cardiac event monitors with extended memory and continuous measurement with remote transmission.

• ILR — Implantable loop recorder (insertable cardiac rhythm monitor) for long-term rhythm monitoring.

• CardioMEMS / CM-IHM — Implantable pulmonary artery pressure sensor system for remote hemodynamic monitoring in heart failure.

Name	Number	Type	Effective Date
{"text":"Electrocardiographic Services","status":""},{"text":"20.15","status":""},{"text":"NCD","status":""},{"text":"","status":""}
{"text":"Ambulatory Blood Pressure Monitoring","status":""},{"text":"20.19","status":""},{"text":"NCD","status":""},{"text":"","status":""}
{"text":"Ambulatory Electrocardiograph (AECG) Monitoring","status":""},{"text":"L39490","status":""},{"text":"LCD","status":""},{"text":"","status":""}

OpenPayer

MEDICAL COVERAGE POLICY SERVICE: Cardiac Monitoring

Coverage Summary

Medical Necessity Criteria (by device/category)

Excluded, Experimental & Investigational Devices/Indications

Coding (CPT / ICD-10 / HCPCS groups)

Provider Actions & Documentation Requirements

Background, Evidence Summary & Definitions

Medicare Determinations / Local Coverage Guidance

Revision History