Holter Monitor (PDF)

Coverage Summary

This policy (Policy Number: CP.MP.113) covers medical necessity guidelines for continuous ambulatory electrocardiogram (Holter) monitoring up to 48 hours for adult and pediatric members/enrollees. It specifies qualifying indications for 24–48 hour monitoring and notes other indications are considered not medically necessary. Effective/last review date: 04/23.

Key statistics

Age cohorts covered (adult/pediatric)2

Monitoring duration covered24-48 hours

Representative supporting ICD-10 code groups included14+

Medical-Necessity Criteria

Adult initial coverage (members/enrollees > 18 years)

Covered when ANY of the following indications are present and 24 to 48 hours of monitoring is required:

ANY of the following

Evaluation of unexplained syncope, near-syncope, episodic dizziness, recurrent palpitations, episodic shortness of breath or chest pain
Evaluation of neurological events when transient atrial fibrillation or flutter is suspected
Evaluation of syncope, near-syncope, episodic dizziness, or palpitations in whom a probable cause other than an arrhythmia has been identified but symptoms persist despite treatment of this other cause
Evaluation of members/enrollees with cardiomyopathy, or a first-degree relative with arrhythmogenic right ventricular cardiomyopathy
Evaluation of possible or documented prolonged QT syndromes
To screen for asymptomatic arrhythmia in a members/enrollees with Brugada syndrome

Pediatric initial coverage (members/enrollees ≤ 18 years)

Covered when ANY of the following indications are present and 24 to 48 hours of monitoring is required:

ANY of the following

Evaluation of syncope, near-syncope, or dizziness in members/enrollees with identified cardiac disease, previously documented arrhythmia, or pacemaker dependency
Evaluation of syncope or near-syncope associated with exertion when cause is not established
Evaluation of unexplained syncope, near-syncope, or sustained palpitation when there is no overt clinical evidence of heart disease
Assessment of efficacy of medications for arrhythmia following initiation of treatment or during rapid somatic growth
Evaluation of patients with cardiomyopathy, or a first-degree relative with arrhythmogenic right ventricular cardiomyopathy

Not medically necessary

Holter monitoring up to 48 hours is considered not medically necessary for:

Any indication not included in this policy because efficacy has not been established

Coding

Covered CPT codes (Holter up to 48 hours)CPTCovered

93224	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
93225	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)
93226	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report
93227	External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional

ICD-10-CM diagnosis codes that support coverage criteriaICD-10

G45.9	Transient cerebral ischemic attack, unspecified
G71.00-G71.09	Muscular dystrophy
G99.0	Autonomic neuropathy in diseases classified elsewhere
I20.0-I20.9	Angina pectoris
I24.0-I24.9	Other acute ischemic heart diseases
I25.10	Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.112	Atherosclerosic heart disease of native coronary artery with refractory angina pectoris
I25.702	Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris
I25.712	Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris
I25.722	Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris

1–10 of 59

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Provider Actions

Documentation Required

Document indication supporting medical necessity

Provider must document one of the listed qualifying indications (adult or pediatric) and that 24-48 hours of monitoring is required to meet coverage; claims should include supporting ICD-10 diagnosis codes.

Billing Rule

Use appropriate CPT codes for up to 48-hour Holter monitoring

Report CPT codes 93224, 93225, 93226, and/or 93227 as applicable for Holter monitoring up to 48 hours per the descriptors in policy.

93224
93225
93226
93227

Background & Evidence

Ambulatory ECG (Holter) monitoring continuously records the heart's electrical activity for a period of 24 to 48 hours to correlate symptoms with arrhythmias and to evaluate conduction abnormalities. It permits patients to mark symptomatic events so recorded data can be analyzed to determine whether symptoms such as palpitations, syncope/near-syncope, dizziness, shortness of breath, chest pain, or episodic fatigue are related to arrhythmia, and can document arrhythmias that lead to directed therapy or demonstrate symptoms not related to arrhythmia.

Holter monitoring is useful to assess the efficacy of antiarrhythmic medications and other treatments, to detect proarrhythmic responses, and to evaluate pacemaker and ICD function (including suspected device malfunction and assistance with programming). Ambulatory ECG can also provide information about myocardial ischemia (e.g., ST-segment changes) and may be beneficial in suspected variant angina.

In pediatric populations Holter monitoring is used for the same indications as adults and for pediatric-specific concerns: monitoring after congenital heart surgery to identify late arrhythmias, assessing medication dosing during growth, evaluation of hypertrophic or dilated cardiomyopathies and prolonged QT syndromes, and assessment of asymptomatic congenital complete AV block to identify children at increased risk for sudden arrhythmic events.

Guideline and evidence references cited in this policy include ACC/AHA ambulatory ECG guidelines and multiple specialty society statements (references 1–10). Specific sources referenced include the ACC/AHA 1999 ambulatory ECG guidelines and more recent specialty society guidance and consensus statements (see referenced items such as ACC/AHA and ISHNE-HRS publications).

Definition

Key policy terms and scope

Medicare Determinations

Name	Number	Type	Effective
Electrocardiographic (EKG or ECG) monitoring (Holter or real-time monitoring)	L34636	LCD	2015-10-01 (revised 2021-10-28)
Long-term wearable electrocardiographic monitoring (WEM)	L33380	LCD	2015-10-01 (revised 2019-10-01)

Revision History

04/23revision_approvalLatest

Added ICD-10 codes I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762 and I25.792 to policy.

09/22revision

Added 'Evaluation of recurrent chronic heart failure, when arrhythmia is suspected' and 'Evaluation of possible arrhythmias post ablation procedures' to adult criteria (noted as minor rewording with no clinical significance).

08/17revision

Added evaluation of cardiomyopathy (and first-degree relative with arrhythmogenic right ventricular cardiomyopathy), expanded pediatric cardiomyopathy criteria, and added prolonged QT and Brugada screening in adults.