Real-Time Mobile Cardiac Outpatient Telemetry
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Clinical coverage policy governing use and medical necessity criteria for real-time mobile cardiac telemetry (MCT/MCOT) for Network Health Plan members, including Medicare Advantage where CMS NCDs/LCDs apply.
No material clinical or coverage changes in this revision.
Coverage Criteria — Medical Necessity for MCT/MCOT
Covered Indications (up to 30 consecutive days)
Covered when ANY of the following indications are met (monitoring limited to no longer than 30 consecutive days):
Use of MCT/MCOT for any purpose other than the specific indications listed in this policy is considered not medically necessary. This exclusion applies broadly and is not limited to the examples given in the criteria; services provided outside the covered indications may be denied.
Specifically, MCT/MCOT for ongoing medical management after diagnosis, medication management, or for asymptomatic patients is considered not medically necessary and is not covered under this policy.
Coding and Test Recency
| 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: physician review and interpretation with report. |
| 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 physician prescribed transmission of daily and emergent data reports. |
Provider Actions and Prior Authorization
Prior authorization and coverage alignment
MCT/MCOT is covered only when the policy criteria are met and monitoring is limited to no more than 30 consecutive days. For Medicare Advantage members, coverage decisions follow applicable CMS National and Local Coverage Determinations (NCDs/LCDs); when a CMS determination is absent, this policy applies.
- Covered per criteria for up to 30 consecutive days
- Medicare Advantage members: follow CMS NCDs/LCDs; in absence of CMS determination, this policy applies
Prior Holter requirement (Holter ≤60 days)
For certain indications, a non-diagnostic Holter monitor completed no more than 60 days prior is required and must have failed to identify a definitive diagnosis before MCT/MCOT is covered.
- Holter must be non-diagnostic and completed ≤60 days prior
- Requirement applies when symptoms occur infrequently or unpredictably and longer monitoring is deemed necessary
Verify eligibility and benefit coverage in member’s plan documents
Determine member eligibility and benefit specifics by consulting the member's coverage document (Certificate of Coverage, Evidence of Coverage, or Summary Plan Description). For Medicare Advantage members, applicable CMS NCDs/LCDs also apply.
- Refer to the member’s Certificate of Coverage, Evidence of Coverage, or Summary Plan Description to determine contract-specific coverage
- Medicare Advantage members follow applicable CMS NCDs/LCDs
Not medically necessary uses — potential denial risk
Use of MCT/MCOT for any reason other than the specified covered indications is considered not medically necessary and may be denied. Examples include ongoing medical management after diagnosis, use for medication management, or monitoring asymptomatic patients.
- Not medically necessary when used for ongoing medical management after diagnosis
- Not medically necessary for medication management
- Not medically necessary for asymptomatic patients
Background
Coverage for real-time mobile cardiac telemetry (MCT) or mobile cardiac outpatient telemetry (MCOT) is subject to the terms, conditions, and limitations of the member's coverage document (for example, Certificate of Coverage, Evidence of Coverage, or Summary Plan Description). Providers should confirm eligibility and any plan-specific restrictions prior to ordering monitoring.
Definitions
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