Confirm prior authorization requirement with member's plan

Utilization review may be performed using these Clinical UM Guidelines; contact the customer service number on the back of the member's card or the member's plan to determine if review/authorization is required. The member's contract benefits in effect on the date of service take precedence in determining eligibility for coverage.

Prior authorization applies to listed CPT codes

Prior authorization expectations are tied to the listed CPT/HCPCS codes for external ambulatory cardiac monitoring; services billed using the listed codes (including 93241–93248, 93268–93272 and unlisted 93799 when specified) may require review/authorization.

• Codes referenced repeatedly as the basis for prior authorization: 93241–93248, 93268–93272, and 93799.

Prior authorization may be required for listed monitoring services

Prior authorization may be required for services described by the policy (continuous rhythm recording and patient-activated/auto-activated event recorders up to 30 days); check plan-specific utilization review requirements before ordering.

Reference medically necessary codes in prior auth requests

The policy’s medically necessary section references the specific CPT groups for covered services; prior authorization requests should reference those same codes when documenting medical necessity.

• Reference the 'When services may be Medically Necessary' code lists in authorization submissions.

Include listed CPTs and specified 93799 in prior auth

Prior authorization/coverage applies to external ambulatory cardiac monitoring services described by the listed CPT codes and to the unlisted cardiovascular procedure when specified as an in‑office connection/review (93799); submit the appropriate code(s) when requesting authorization.

• Include 93799 only when specified as in‑office connection/review/interpretation of an external patient‑activated recorder without 24‑hour attended monitoring.

Bill specific codes and specify duration/attended monitoring

Bill the specific CPT/HCPCS code that describes the monitored service and indicate the monitoring duration and whether 24‑hour attended monitoring was provided; for 93799, specify that the service was an in‑office connection/review and interpretation of an external patient‑activated recorder without 24‑hour attended monitoring.

• Report exact CPT/HCPCS code matching the device/duration.
• Document and report whether monitoring was 24‑hour attended.
• If billing 93799, state that it was used for in‑office connection/review/interpretation without 24‑hour attended monitoring.

Use the policy’s listed CPT groups for prior auth

Prior authorization guidance references continuous external recording codes for >7 up to 15 days (93245–93248), event recorder codes up to 30 days (93268, 93270–93272), and the unlisted cardiovascular procedure for specified in-office review (93799); use these codes when seeking authorization.

Prior auth applies to listed CPTs and 93799 for in‑office review

Prior authorization/coverage guidance applies when billing the listed CPTs and the unlisted procedure (93799) for in‑office connection or review/interpretation of external patient‑activated event recorders without 24‑hour attended monitoring; include the applicable CPT(s) on the authorization and claim.

Prior authorization covers listed continuous and event recorder codes

Coverage/prior authorization applies to CPT codes 93245–93248 (continuous external recording >7 up to 15 days), 93268–93272 (event recorders up to 30 days, possibly with 24‑hour attended monitoring), and 93799 when specified for in‑office connection/review; ensure services billed with these codes meet policy medical necessity.

Ensure billed codes meet device/duration medical necessity

Services billed with the listed codes must meet the policy’s medical necessity criteria for the specified device type and monitoring duration; prior authorization (if required) is tied to those codes.

Use consistent codes for authorization and claims

Prior authorization and coding guidance reference codes 93245–93248 for continuous recording (>7 up to 15 days), 93268–93272 for event recorders (up to 30 days, with remote download/24‑hour attended options), and 93799 for in‑office connection/review without 24‑hour attended monitoring; use these codes consistently across authorization and claims.

Confirm code‑to‑service mapping before authorizing

Coverage descriptions include continuous external ECG codes 93245–93248 (>7 up to 15 days) and external event recorder codes 93268, 93270–93272 (up to 30 days with remote download and possible 24‑hour attended monitoring); 93799 is referenced when used for in‑office connection/review without 24‑hour attended monitoring.

Prior auth/coverage tied to code‑specific durations

Prior authorization/coverage applies to continuous ECG recording for more than 7 up to 15 days (93245–93248) and to external patient‑activated/event recording up to 30 days (93268, 93270–93272); 93799 may be used when specified for in‑office connection/review without 24‑hour attended monitoring.

Authorization may be required for covered monitoring services

Services described (continuous recording >7 up to 15 days and event recording up to 30 days including the listed CPTs and 93799 when specified) are covered when the policy’s medical necessity criteria are met; prior authorization may be required per payer processes.

Match CPT coding to device type and duration

Ensure coding on claims matches the device type and monitoring duration specified in the policy: use 93245–93248 for continuous >7–15 day recording, 93268–93272 for patient/auto‑activated event recording up to 30 days, and 93799 only as specified for in‑office connection/review.

• Confirm the device/duration supports the chosen CPT (continuous vs event).
• Avoid billing continuous codes for event‑recorder services and vice versa.

Step to event monitor for infrequent symptoms (< once/48 hours)

External ambulatory event monitors are an accepted diagnostic alternative to Holter monitoring when symptoms occur less frequently than once every 48 hours; document symptom frequency when ordering an event monitor.

• Note symptom frequency threshold: use event monitor when symptoms are < once every 48 hours.

Apply member contract and confirm plan adjudication policies

Member contract benefits in effect on the date of service must be applied during adjudication; Clinical UM Guidelines may be used in utilization review but plans may choose whether to adopt them—confirm plan-specific processes.

Document modality, duration, and CPT linkage

Documentation submitted should support the selected monitoring modality and duration (e.g., continuous >48 hours up to 7 days, >7 up to 15 days, or event recorder up to 30 days) and explicitly reference the CPT code(s) used.

• State the rationale for the chosen duration and modality.
• Link clinical indication and symptom frequency to the CPT billed.

Document interpretation and in‑office review when billing 93799

When billing for review/interpretation of external patient‑activated recordings, document the review and interpretation; if billing 93799 for in‑office connection/review, document that the service was an in‑office connection or review and interpretation of the external patient‑activated recorder without 24‑hour attended monitoring.

• Include interpretation/report in documentation when billing for review services.
• For 93799, explicitly document that service was in‑office connection/review without 24‑hour attended monitoring.

Document device type, duration, attended monitoring, and indication

Document the device type, monitoring duration (for example >7–15 days for continuous recording or up to 30 days for event recording), whether monitoring was 24‑hour attended, and the clinical indication to support medical necessity for the billed CPT(s).

• Identify device model/type and its capabilities (memory loop, remote download).
• Record symptom frequency and clinical reason for chosen monitoring duration.

Ensure documentation supports code and billed duration

Provider documentation must support the monitoring type and duration billed (e.g., continuous >7 to 15 days billed with 93245–93248; event recording up to 30 days with attended monitoring billed with 93268–93272) or, when performing in‑office connection/review of a patient‑activated recorder without 24‑hour attended monitoring, report 93799 and document that specification.

Include required documentation elements: type, duration, CPT used

Documentation should explicitly identify the type of external ambulatory monitor provided, the monitoring duration billed (e.g., >7–15 days for continuous recording or up to 30 days for event recorders), and the specific CPT/unlisted code used (93245–93248, 93268–93272, or 93799 when applicable).

Document in‑office connection/review when reporting 93799

When billing 93799 for in‑office connection or review/interpretation of an external patient‑activated event recorder without 24‑hour attended monitoring, document the in‑office connection/review and interpretation performed; lack of that specification may affect coverage.

• State that 93799 was used specifically for in‑office connection/review/interpretation without 24‑hour attended monitoring.

Risk of denial if Holter criteria are not met

Ambulatory ECG Holter monitor use is considered not medically necessary when the policy’s stated criteria are not met; examples of non‑covered uses include autonomic cardiac neuropathy associated with diabetes mellitus and after MI with EF ≤ 40%.

Coding denial trigger for procedures billed without criteria

Procedure codes listed in the policy are considered not medically necessary when the associated criteria are not met or for diagnoses not listed; submitting these codes without meeting criteria risks denial.

Coding‑duration mismatch may trigger denial

Using procedure codes that do not align with the device type or monitoring duration described in the policy (for example billing continuous‑recording codes for event‑recorder services or vice versa) may trigger coverage denial if documentation does not support the selection.

• Avoid coding‑duration mismatches between device/duration and CPT.

Denial risk when billing non‑listed codes

Claims may be denied if billed with codes not listed as included/covered for the specified monitoring modality or duration; ensure claims use the CPT codes enumerated in the policy for the service provided.

Specify 93799 use or risk denial

When using unlisted code 93799, specify that it represents in‑office connection or review and interpretation of an external patient‑activated electrocardiographic rhythm‑derived event recorder without 24‑hour attended monitoring; failure to specify this use may lead to coding/coverage denial.

• Include statement that 93799 is for in‑office connection/review/interpretation without 24‑hour attended monitoring.

Denial risk for services not meeting medical necessity

Services that do not meet the policy’s medical necessity criteria for the listed monitoring codes (e.g., 93245–93248, 93268–93272, 93799) may be denied; ensure clinical documentation supports indications and duration before submitting claims.

Risk of denial for claims mismatching listed codes/descriptions

Claims that do not match the listed CPT codes or the specified in‑office connection/review description (for 93799) may be at risk for denial if billed outside the covered codes and descriptions; align coding and description with the policy.

Coding‑duration mismatch is a denial trigger

Using codes that do not match the specified monitoring duration or device type (for example billing codes other than 93245–93248 for >7–15 day continuous recording, or not using 93268–93272 for up to 30‑day attended event monitoring) may trigger denials.

Denial risk for nonconforming services or durations

Coverage is defined only when criteria are met for the listed services and codes; claims for services outside specified monitored durations or not matching described codes may be denied as nonconforming.

Denial risk when device/duration and coding do not conform

Services not meeting the specified device/duration coding combinations (for example outside the listed durations or unsupported code pairings) risk denial; document device capabilities and chosen duration to demonstrate conformity.

Denial risk for nonconforming monitoring services

Claims for monitoring services that do not meet documented medically necessary device/duration criteria (e.g., outside specified durations or without required monitoring capabilities) may be denied; ensure the clinical record supports the selected modality and time window.

Nonconformance with listed device types/durations risks denial

Services not meeting the specified device‑type, duration, or coding (for example outside the stated monitoring durations or not using the listed CPT codes) risk being denied as not meeting the policy’s medically necessary conditions; verify code selection and documentation prior to claim submission.