ModifiedPremera BluecrossPolicy 2.02.08

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders

Get alerted when Policy 2.02.08 changes without checking for updates manually.

Defines medical necessity, site-of-service considerations, documentation, and coding for use of MCOT and ILR devices for outpatient cardiac rhythm monitoring for Premera Blue Cross members.

Policy Summary

PayerPremera Bluecross

PolicyMobile Cardiac Outpatient Telemetry and Implantable Loop Recorders

Policy CodePolicy 2.02.08

Change TypeRevised — added ILR coverage criteria, new CPT/HCPCS codes, and site-of-service ASC review

Effective DateAug 7, 202619d

Last ReviewAug 1, 202613d

Next Review DateN/A

Key ActionObtain and document at least 14 continuous days of non-diagnostic ambulatory cardiac monitoring before requesting ILR implantation.

SourceLink

POLICY UPDATE CHANGES

This policy has been revised (see header noting revised policy and effective date).

Title changed to Mobile Cardiac Telemetry and Implantable Loop Recorders and implantable loop recorders were added as medically necessary when criteria are met.

Additional policy criterion added for ILR to require a prior non-diagnostic or inconclusive ambulatory cardiac monitoring of at least 14 continuous days.

Minor edits clarified that site of service review applies only to implantable loop recorders and does not apply to Indian Health Services (IHS) facilities.

Removed term ambulatory event monitor (AEM) for clarity; wording standardized from 'patient' to 'individual'.

14 daysminimum prior monitoring (days)

33285new CPT code

Related Billing Codes

CPT-33285-INSERTABLE-CARDIAC-RHYTHM-MONITOR-INSERTION-PROGRAMMING

CPT 33285: Insertable Cardiac Rhythm Monitor Insertion and Programming

HCPCS-E0616-IMPLANTABLE-CARDIAC-EVENT-RECORDER

HCPCS E0616: Implantable Cardiac Event Recorder with Memory, Activator and Programmer

CPT-93228-REMOTE-CONTINUOUS-ECG-MONITORING-INTERPRETATION

CPT 93228: Remote Continuous ECG Monitoring Interpretation

CPT-93229-WEARABLE-ECG-MONITOR-PLACEMENT-AND-MONITORING

CPT 93229: Wearable ECG Monitor Placement, Instruction, and Transmission Monitoring

HCPCS-C1764-IMPLANTABLE-CARDIAC-EVENT-RECORDER

HCPCS C1764: Implantable Cardiac Event Recorder

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C1764, E0616new HCPCS

ASC preferredsite-of-service rule

14%AF detection (28-day MCOT)

Coverage Criteria for MCOT and ILR

inv-01: ILR - Covered when ALL met

ILR implantation is considered medically necessary when ALL of the following are met:

ILR criteria: Prior non-diagnostic or inconclusive ambulatory cardiac monitoring of at least 14 continuous days>=14 days

See documentation requirements

Symptoms or indication: Recurrent unexplained episodes of presyncope, syncope, palpitations, or dizziness

Any one of these symptoms qualifies when prior monitoring nondiagnostic

Cryptogenic stroke pathway: Evaluation for suspected atrial fibrillation as a cause of cryptogenic stroke with a negative standard workup including 24-hour Holter monitoring

Meets criteria when standard AF workup is negative

inv-02: MCOT - Covered when ALL met

MCOT is considered medically necessary when ALL of the following are met:

MCOT prior monitoring: Previous external ambulatory cardiac event monitoring of at least 14 continuous days with a non-diagnostic outcome>=14 days

Required before MCOT

MCOT indication: Symptomatic cardiac arrhythmia occurring less frequently than once every 48 hours (palpitations, dizziness, presyncope, syncope)symptoms < once every 48 hours

Or satisfy the cryptogenic stroke evaluation pathway

Cryptogenic stroke indication: Evaluation of suspected atrial fibrillation as a cause of cryptogenic stroke when short-term Holter (24–48 hr) or telemetry is nondiagnostic

Alternate pathway to qualify for MCOT

inv-03: ILR Site of Service - Covered when criteria met

Site of service for ILR implantation is determined per ASC preference and exceptions:

Acceptable sites: Ambulatory surgical center (preferred); off‑campus outpatient hospital/medical center; on‑campus outpatient hospital/medical center

ASC is preferred when criteria met

Hospital outpatient allowed when: No qualifying ASC within 30 miles, no ASC with necessary equipment or physician privileges, ASC guideline prohibitions, individual aged 18 or younger, concurrent service requiring hospital outpatient department, or clinical conditions increasing perioperative risk (e.g., ASA III+, recent MI, unstable heart failure, advanced liver disease, severe pulmonary disease)

If any apply, hospital outpatient site is medically necessary

inv-04: Prolonged monitoring and device selection

Covered when ALL of the following are met (narrative criteria preserved):

General indication: Individual has signs or symptoms suggestive of arrhythmia (e.g., syncope, presyncope, palpitations, cryptogenic stroke) and initial evaluation including history, physical, ECG, and short‑term monitoring (24–48 hr Holter) was nondiagnosticsymptom frequency and nondiagnostic prior testing

Supports escalation to prolonged monitoring

Device selection by symptom frequency: If transient loss of consciousness occurs several times/week use Holter; if every 1–2 weeks consider external event recorder; if less than once every 2 weeks consider implantable event recorder (ILR)frequency-based device selection

Based on guideline recommendations

Role of MCOT: MCOT may be used when real‑time detection could change immediate management (emergent interventions) or when higher diagnostic yield versus autotrigger event recorders is needed, recognizing limited evidence for improved long‑term outcomes

inv-05: MCOT / Extended monitoring coverage criteria

Covered when ALL of the following are met for outpatient MCOT in select patients (as supported by clinical input and guideline summaries):

MCOT clinical input criteria: 1) Infrequent symptoms (< every 48 hours) suggestive of cardiac arrhythmia (severe palpitations, dizziness, clinically significant presyncope or syncope); and 2) Holter monitor and/or external event monitor has been nondiagnostic or is contraindicated; and 3) Documentation that real‑time monitoring is essential for patient safety and will lead to immediate clinical changes (eg, medication adjustment or emergent procedure)symptom frequency: less than every 48 hours

From 2025 clinical input and guideline summaries

Alternate covered indication: Evaluation of cryptogenic stroke thought to be caused by atrial fibrillation when 24–48 hour Holter or 48‑hour telemetry is nondiagnosticpost‑stroke monitoring after nondiagnostic short‑term monitoring

Supported by guideline recommendations for extended monitoring after cryptogenic stroke

inv-06: Implantable Loop Recorder (ILR) Initial Coverage

Covered when ALL of the following are met

ILR initial coverage: Prior non‑diagnostic or inconclusive ambulatory cardiac monitoring of at least 14 continuous days has been performed>=14 days

Added requirement in policy update; documentation must be provided

Other uses of mobile cardiac outpatient telemetry (MCOT) and implantable loop recorders (ILRs) are considered not medically necessary when the coverage criteria in this policy are not met. Examples explicitly listed include monitoring asymptomatic individuals for risk factors for arrhythmia, using these devices solely to assess the effectiveness of antiarrhythmic medications, or employing them to detect myocardial ischemia by monitoring for ST‑segment changes.

The evidence assessing whether the real‑time transmission capability of MCOT improves clinical outcomes is limited. Systematic summaries and comparative studies show MCOT detects arrhythmias at rates at least comparable with ambulatory event monitors and may permit emergent intervention because of near real‑time notification; one series estimated approximately 1% of detected events could be considered potentially emergent. However, randomized trials demonstrating that real‑time MCOT reduces mortality or major cardiac events were not identified, and the available evidence is insufficient to conclude that real‑time monitoring improves net health outcomes.

Clinical input and the evidence base do not support a clear advantage of real‑time MCOT over appropriately selected external event or longer‑wear external monitors for all patients. MCOT offers the theoretical and practical benefit of immediate transmission and potential emergent notification, which may be important when a detected rhythm would prompt urgent intervention; however, reviewers and specialty respondents have not reached consensus that this capability provides incremental outcome benefit for every indication. Device selection should therefore be guided by symptom frequency and the clinical scenario—reserving MCOT when real‑time detection is essential and using less‑intensive external monitors when appropriate.

This policy addresses coverage and medical‑necessity criteria for categories of ambulatory cardiac rhythm monitoring devices (for example, external MCOT systems and implantable loop recorders). A comprehensive catalog or detailed technical descriptions of individual manufacturer devices and models is beyond the scope of this policy; a sampling of US Food and Drug Administration product codes is provided for reference.

Expanded not medically necessary language confirms that monitoring or ILR placement for individuals without symptoms related to arrhythmia (i.e., asymptomatic individuals) is considered not medically necessary. The policy update also clarifies that ILR coverage requires meeting the stated clinical criteria and documentation requirements before implantation will be considered.

Examples of situations that do not meet the policy criteria and are therefore not medically necessary include: monitoring an asymptomatic individual solely to screen for arrhythmia risk factors; prolonged monitoring used only to document response to antiarrhythmic medications rather than to diagnose intermittent symptomatic arrhythmia; and use of MCOT or ILR for detection of myocardial ischemia by ST‑segment surveillance.

Routine or routine‑use deployment of MCOT solely to achieve unproven improvements in outcomes (for example, reduced mortality) is unsupported by the randomized‑trial evidence available in this review. While MCOT increases arrhythmia detection and can shorten time to diagnosis, no randomized studies have shown that real‑time outpatient telemetry decreases major cardiac events or mortality.

Implantable memory loop devices have evolved in design and size. Respondents noted that newer, smaller generators improve ease of use and the likelihood of obtaining clinically useful recordings compared with older larger devices; however, earlier reviews did not reach consensus that these device‑generation improvements translate into proven clinical outcome benefits in all settings. Regulatory product codes are provided for category reference but individualized device descriptions remain outside the policy scope.

When originally created (history entry 08/09/16) the policy classified use of MCOT as investigational. Subsequent literature reviews, clinical input, and periodic updates led to revision of that stance: MCOT indications were refined and, in later updates, implantable loop recorders were added as medically necessary when the updated clinical criteria are met. The policy history documents these changes and the coding updates made over time.

Consistent with the expanded not medically necessary statement, insertion of implantable loop recorders and monitoring for individuals without relevant symptoms is considered not medically necessary. ILR placement requires documentation that the individual meets all specified clinical criteria, including prior non‑diagnostic external monitoring when required.

Coding and Billing

Covered CPT Codes (procedural for ILR insertion)CPTCovered

33285

Insertion, subcutaneous cardiac rhythm monitor, including program.

Covered CPT Codes (MCOT monitoring and support)CPTCovered

93228

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real-time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional.

93229

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional.

HCPCS codes for implantable recordersHCPCSCovered

C1764	Event recorder, cardiac (implantable).
E0616	Implantable cardiac event recorder with memory, activator, and programmer

FDA product codes (examples)mixed

DSH	US FDA product code (category example) listed in policy
DXH	US FDA product code (category example) listed in policy
DQK	US FDA product code (category example) listed in policy
DSI	US FDA product code (category example) listed in policy
MXD	US FDA product code (category example) listed in policy
MHX	US FDA product code (category example) listed in policy

Medicare coverage referencemixed

medicare NCD

CMS national coverage determination for electrocardiographic services (descriptive reference)

Removed CPT Codes (historical)CPT

0295T	CPT code removed per coding update (historical)
0296T	CPT code removed per coding update (historical)
0297T	CPT code removed per coding update (historical)
0298T	CPT code removed per coding update (historical)

FDA Product Codesmixed

DSH	FDA product code
DXH	FDA product code
DQK	FDA product code
DSI	FDA product code
MXD	FDA product code
MHX	FDA product code

Added CPT CodesCPTCovered

33285

Insertion of implantable loop recorder

Added HCPCS CodesHCPCSCovered

C1764	Implantable cardiac monitor device (HCPCS)
E0616	External cardiac monitor (HCPCS) or related supply

Minimum prior ambulatory monitoring (key value)

Minimum prior ambulatory monitoring>= 14 continuous days of prior external ambulatory cardiac monitoring is required before considering ILR or MCOT

Documentation requirementMedical record must document prior non-diagnostic or inconclusive ambulatory cardiac monitoring of at least 14 continuous days

Applies toBoth patient-activated and auto-activated implantable loop recorders (ILRs) and external MCOT when escalation from shorter monitoring is needed

Symptom frequency threshold for MCOT consideration

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for implantation of implantable loop recorders (ILR) and for use of prolonged external monitors such as mobile cardiac outpatient telemetry (MCOT) when the device/service meets the policy's medical necessity criteria. Requests must include documentation that prior short-term ambulatory monitoring was performed and was non-diagnostic (see documentation requirements).

Prior authorization required for ILR implantation and MCOT devices.
Prior authorization applies to implantable and prolonged external monitoring codes (see coding history and current code set).

Billing Rule

Prior Authorization / Coding Note

Prior authorization and billing must reflect current coding guidance. Historical CPT codes 0295T–0298T were removed; policy additions include CPT 33285 and HCPCS codes C1764 and E0616 (see history). Check the payer's current code table when submitting authorizations and claims.

Definitions

ILR definition (key value)

Definition (ILR)A subcutaneously implanted device that records cardiac rhythm for prolonged periods and can be patient- or auto-activated to capture infrequent symptoms

Typical clinical useUseful for recurrent, infrequent, unexplained syncope or extended detection of occult atrial fibrillation after cryptogenic stroke

Comparative rationaleStudies report higher arrhythmia detection rates versus shorter external monitoring, supporting use when noninvasive monitoring is nondiagnostic

MCOT definition (key value)

Definition (MCOT)Continuously recording or autotriggered external devices that transmit ECG data in near real-time to a remote monitoring center for analysis and physician notification

Key featuresConcurrent computerized real-time data analysis with transmission to an attended surveillance center; supports near-real-time review and alerts

Background and Evidence Summary

ILRs and MCOT are intended to detect intermittent arrhythmias that are missed on brief in‑office testing. ILRs are implanted subcutaneously to provide prolonged automatic or patient‑activated surveillance for infrequent but clinically important events (for example, unexplained syncope or to detect atrial fibrillation after cryptogenic stroke). MCOT refers to external systems that continuously record or autotrigger and transmit data in near real‑time to a monitoring center; both modalities aim to improve diagnostic yield when symptoms are sporadic.

Policy Revision History

08/09/2016policy_created

New policy added to Cardiology section; initial statement: use of MCOT considered investigational; effective date scheduled (01/01/2017, later revised).

10/25/2016effective_date_revision

Effective date revised from 01/01/2017 to 03/01/2017.

02/24/2017effective_date_revision

Effective date revised to 03/15/2017.

Policy Summary

PayerPremera Bluecross

PolicyMobile Cardiac Outpatient Telemetry and Implantable Loop Recorders

Policy CodePolicy 2.02.08

Change TypeRevised — added ILR coverage criteria, new CPT/HCPCS codes, and site-of-service ASC review

Effective DateAug 7, 202619d

Last ReviewAug 1, 202613d

Next Review DateN/A

Key ActionObtain and document at least 14 continuous days of non-diagnostic ambulatory cardiac monitoring before requesting ILR implantation.

SourceLink

On This Page

clinical scenario where real‑time notification influences management

No RCTs demonstrating reduced mortality with MCOT

When to consider ILR: Consider ILR for individuals with infrequent but concerning symptoms (eg, unexplained syncope) when noninvasive monitoring is nondiagnostic and prolonged monitoring is needed to capture eventsinfrequent symptoms and nondiagnostic external monitoring

ILR associated with higher diagnostic yield versus shorter monitoring

Symptom frequency threshold

Symptoms occurring less frequently than once every 48 hours (i.e., < once every 48 hours)

Indications tied to frequencyThreshold applies to symptomatic cardiac arrhythmia (palpitations, dizziness, presyncope, syncope) considered for MCOT after >=14 days of nondiagnostic external monitoring

Alternate pathwayEvaluation for suspected atrial fibrillation as a cause of cryptogenic stroke is an alternate covered indication regardless of exact symptom frequency when short-term monitoring is nondiagnostic

Prior ambulatory monitoring duration (redundant/new code note)

Prior ambulatory monitoring duration (policy note)>= 14 continuous days (added requirement in policy update effective August 7, 2026)

Evidence of prior monitoringDocumentation should demonstrate prior non-diagnostic or inconclusive ambulatory cardiac monitoring of at least 14 continuous days before ILR placement

Redundant/new code noteRequirement reiterated in updated policy history that added ILR coverage and related codes (CPT 33285; HCPCS C1764, E0616)

Removed CPT codes: 0295T–0298T (historical).
Added CPT: 33285; HCPCS: C1764, E0616.

Note

Evidence Limitations May Affect Coverage

Evidence limitations affect coverage determinations for prolonged and real-time outpatient telemetry. Although prolonged monitors and ILRs increase arrhythmia detection compared with short-term monitoring, randomized data demonstrating improvements in clinical outcomes (mortality or major morbidity) from real-time MCOT are limited. The absence of demonstrated outcome benefit in some settings is a factor in the policy's coverage determinations.

MCOT increases detection rates, but trials have not consistently shown improved clinical outcomes attributable to real-time monitoring.
ILR shows higher diagnostic yield vs short-term monitoring; outcome benefit depends on downstream management.

Documentation Required

Documentation-Dependent Coverage

Coverage is documentation-dependent. Medical records submitted for prior authorization and claims review must demonstrate that medical necessity criteria are met. Lack of sufficient documentation may result in denial of authorization or payment.

Submit office visit notes with relevant history and physical.
Include prior monitoring reports demonstrating non-diagnostic results and duration.
Provide device-specific rationale tying symptoms to the selected monitoring strategy.

Note

Not Stated / Confirm with Payer

Some items are not explicitly stated in this document segment and may require clarification from the payer during prior authorization. Examples include specific form requirements, expected turnaround time for decisions, and any additional insurer-specific preauthorization forms or attachments.

If not specified, confirm with Premera Blue Cross which prior authorization form and supporting documents are required.
Clarify any member benefit or site-of-service rules that may affect coverage (e.g., ASC access exceptions).

Denial Risk

Denial Risk for Asymptomatic Monitoring

Use of ILRs or prolonged monitoring for asymptomatic surveillance is expanded in the policy's not medically necessary statements; such use carries a high risk of denial. Prior authorization submissions for asymptomatic monitoring are likely to be denied unless documentation meets specific, supported indications.

Monitoring asymptomatic individuals for arrhythmia risk factors or medication effectiveness is considered not medically necessary.
Documented symptomatic indications (syncope, presyncope, palpitations, dizziness) or evaluation for AF after cryptogenic stroke are required for coverage.

Documentation Required

Required Documentation

Required documentation for prior authorization and claims includes both clinical notes and prior monitoring results. Submissions must demonstrate the chronology of symptoms and prior testing, and provide device selection rationale based on symptom frequency and nature.

Office visit notes with history and physical and symptom frequency.
Results and interpretation of prior ECG and prior ambulatory monitoring (showing non-diagnostic outcome).
For ILR: documentation of >=14 continuous days of prior external ambulatory cardiac monitoring that was non-diagnostic.
For MCOT: documentation of at least 14 continuous days of prior external ambulatory cardiac monitoring that was non-diagnostic (unless MCOT is being used per specified criteria).

Documentation Required

Required Clinical Justification

Provide clear clinical justification in the authorization request: relation of symptoms to suspected arrhythmia, frequency and duration of events, prior non-diagnostic testing, and specific indication (e.g., unexplained recurrent syncope, presyncope, palpitations, or evaluation for AF after cryptogenic stroke). For ILR, show that prior short-term monitoring (>=14 days) was non-diagnostic.

State symptom type and frequency (e.g., infrequent unexplained syncope).
Attach prior non-diagnostic ECG and ambulatory monitoring reports (>=14 days).
Indicate intended diagnostic goal (e.g., correlate symptoms with rhythm, detect occult AF after cryptogenic stroke).

Note

Monitor Selection Guidance

Choose the monitoring modality based on the frequency and nature of the individual's symptoms and guideline recommendations: short-term Holter for daily symptoms, external event monitors or patch recorders for symptoms occurring over weeks, MCOT for frequent symptoms requiring real-time review or high-risk patients, and ILR for recurrent, infrequent, unexplained syncope where prolonged monitoring is needed.

Holter monitor: symptoms frequent enough to be captured within 24–72 hours.
External event monitor/patch: symptoms likely within 2–6 weeks.
MCOT: spontaneous symptoms related to syncope with need for real-time monitoring or high-risk patients.
ILR: recurrent, infrequent, unexplained syncope or when >=14 days of prior external monitoring was non-diagnostic.

Prior Authorization

Prior Ambulatory Monitoring Required

Prior ambulatory cardiac monitoring for at least 14 continuous days that resulted in a non-diagnostic or inconclusive outcome is required before consideration of ILR implantation (and is required for MCOT in many situations as outlined). Ensure prior monitoring reports are included with the authorization request.

Prior external ambulatory cardiac monitoring >=14 continuous days with documented non-diagnostic outcome is required for ILR candidacy.
For MCOT, prior external ambulatory monitoring >=14 days with non-diagnostic outcome is required for certain indications.
Attach monitoring device reports and interpretation to support the non-diagnostic conclusion.

Use caseConsidered when real-time detection could change immediate management or when symptoms are infrequent and prior shorter monitoring was nondiagnostic

Holter monitor definition

Definition (Holter monitor)A continuously worn device recording cardiac electrical activity continuously for 24–72 hours (traditionally 3-channel; some devices up to 12 channels)

Typical duration24–72 hours; used when symptoms occur daily or very frequently

RoleShort-term comprehensive rhythm assessment; not the focus of prolonged monitoring policy

Event recorder (noncontinuous) definition

Definition (Event recorder - noncontinuous)A device not worn continuously that is activated by the individual when symptoms occur and stores events in memory for later review

ActivationPatient-activated (individual-triggered) or autotriggered in some models

LimitationsDiagnostic yield depends on patient recognition of symptoms; single-lead recordings may limit localization

External memory loop device definition

Definition (External memory loop device)A continuously worn device that records a single channel in a refreshed looped memory and preserves pre- and post-trigger data when activated (individual- or autotriggered)

Captured intervalPreserves several seconds to minutes of pre- and post-event data (e.g., preceding 30–90 seconds and following ~60 seconds)

Trigger modesIndividual activation or automated detection algorithms can trigger recording

Implantable loop recorder (ILR) definition (alternate chunk set)

Definition (Implantable loop recorder - alternate)An implantable memory loop device placed subcutaneously in the precordial region that continuously monitors rhythm and can be patient- or auto-activated to capture infrequent events

Device examplesReveal XT ICM (Medtronic); Confirm Rx Insertable Cardiac Monitor (Abbott); BioMonitor (Biotronik)

Clinical advantageProvides long-term monitoring (months to years) with higher likelihood of capturing infrequent arrhythmias compared with short-term external monitors

Mobile cardiac outpatient telemetry (MCOT) detailed definition

Detailed MCOT definitionExternal mobile cardiovascular telemetry that provides electrocardiographic recording with concurrent computerized real-time data analysis and transmission to a remote attended surveillance center for up to 30 days, with physician review and report (CPT 93228/93229 descriptions)

ComponentsIncludes continuous or autotriggered recording, daily technical support, attended surveillance, and emergent data reporting depending on code and service

DurationUp to 30 days of monitored transmission as described in CPT code descriptors

Mobile cardiac telemetry (MCOT) concise definition

Concise MCOT definitionContinuous multilead external monitoring that streams data and can autodetect events and generate immediate alarms without patient interaction

Alternative nameAlso referred to as mobile cardiac telemetry in guideline summaries

Practical considerationMay require daily electrode changes and has limitations for long-term patient acceptance

Implantable cardiac monitor (ILR) definition

Implantable cardiac monitor (ILR)Long-term implantable device useful for recurrent, infrequent, unexplained syncope and for extended detection of occult atrial fibrillation after cryptogenic stroke

Clinical recommendationGuidelines (AHA/ACC/HRS) state implantable cardiac monitors can be useful for selected ambulatory patients with syncope or post-stroke monitoring

Monitoring durationProvides prolonged surveillance over months to years compared with Holter or external loop recorders

FDA product codes (definition/list reference)

FDA product codes listedUS FDA product codes cited in policy examples: DSH, DXH, DQK, DSI, MXD, MHX

PurposeProvided as regulatory category references for device types in the policy's Regulatory Status section

Not exhaustiveRepresents examples of device categories rather than a complete device registry

MCOT / ILR umbrella definition

Umbrella definition (MCOT/ILR)MCOT and ILR represent ambulatory cardiac monitoring modalities: MCOT denotes external continuous/autotriggered telemetry with near-real-time transmission and analysis; ILR denotes subcutaneous implantable monitors providing long-term automatic rhythm surveillance

Intended goalBoth modalities aim to detect intermittent arrhythmias missed by brief in-office ECGs to guide diagnosis and management

Device selection principleChoice between MCOT, external loop/event recorders, Holter, and ILR should be based on symptom frequency, invasiveness, and whether real-time detection will change immediate management

03/15/2017effective_date_revision

Effective date revised to 03/17/2017.

03/17/2017effective_date_revision

Effective date revised to 03/31/2017.

03/23/2017coding_update

Coding update: removed CPT codes 0295T–0298T; effective date revised to 03/24/2017; minor formatting updates.

08/01/2017annual_review

Annual review approved July 11, 2017; no changes to policy statement.

08/01/2018annual_review

Annual review approved July 13, 2018; literature review through March 2018 added; policy statement unchanged.

08/01/2019annual_review

Annual review approved July 25, 2019; literature review through March 2019 added; policy statements unchanged.

08/01/2020annual_review

Annual review approved July 2, 2020; literature review through May 2020 added; policy statements unchanged.

08/01/2021annual_review

Annual review approved July 9, 2021; literature review through March 25, 2021 added; policy statement unchanged.

06/01/2022interim_review

Interim review approved May 9, 2022; minor edits for clarity; policy intent unchanged.

08/01/2022annual_review

Annual review approved July 11, 2022; literature review through April 8, 2022 added; policy statement unchanged except for a minor edit.

08/01/2023annual_review_with_updateLatest

Annual review approved July 10, 2023; policy updated with literature review through April 11, 2023 and references added; title and coverage updated to add implantable loop recorders (ILRs), require prior non-diagnostic ambulatory monitoring >=14 days, and add CPT 33285 and HCPCS C1764 and E0616.

Material policy changes summarized from the header: added CPT code 33285 and HCPCS codes C1764 and E0616; implantable loop recorders were added as medically necessary when all ILR criteria are met, including a newly added requirement for prior non‑diagnostic ambulatory monitoring of at least 14 continuous days; and site‑of‑service review for ILR implantation (ASC preference with specified exceptions) was added and linked to related policy 11.01.525.

Catch payer policy changes before they impact reimbursement

Catch payer policy changes before they impact reimbursement

OpenPayer

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders

Related Billing Codes

Coverage Criteria for MCOT and ILR

Coding and Billing

Provider Actions, Prior Authorization, and Documentation

Definitions

Background and Evidence Summary

Policy Revision History