CurrentCentenePolicy CP.MP.243

Implantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria

Medical necessity criteria and coding guidance for implantation, replacement, and use of implantable loop recorders/implantable cardiac monitors for members of Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyImplantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria

Policy CodePolicy CP.MP.243

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization showing the patient meets one of the listed medical necessity indications and that external ambulatory monitoring was inconclusive or contraindicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 + replacementPrimary covered indication groups

2–4 yrsTypical device longevity

Multiple codesCoding references

ACC/AHA/ESCGuideline sources cited

25+References

Centene

Policy Summary

PayerCentene

PolicyImplantable Loop Recorder (ILR) / Implantable Cardiac Monitor (ICM) Coverage Criteria

Policy CodePolicy CP.MP.243

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization showing the patient meets one of the listed medical necessity indications and that external ambulatory monitoring was inconclusive or contraindicated.

SourceLink

On This Page

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Medical Necessity and Coverage Criteria

Initial implantation - Medically necessary indications

Covered when ANY of the following indications are met:

Initial Indications: A. Suspected silent atrial fibrillation (AF) in the setting of cryptogenic stroke, when 30-day external ambulatory monitoring is inconclusive or contraindicated;see text

From policy: cryptogenic stroke with inconclusive/contraindicated 30-day monitoring

Initial Indications: B. Suspected or known ventricular arrhythmia when 30-day external ambulatory monitoring is inconclusive or contraindicated;see text

From policy: ventricular arrhythmia with inconclusive/contraindicated 30-day monitoring

Initial Indications: C. History of structural or infiltrative heart disease (e.g., valvular aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease) AND both of the following: (1) high risk for arrhythmias (e.g., family history, symptoms, anatomy of structural heart disease); (2) 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated;see text

Two-part requirement per policy

Initial Indications: D. Recurrent, unexplained syncope or presyncope AND both of the following: (1) cardiac arrhythmia is suspected and external ambulatory monitoring (e.g., 30-day external loop recorder) is inconclusive or contraindicated; (2) symptoms are infrequent (e.g., less than once per month).see text

Two-part requirement per policy; infrequent defined as less than once per month

Secondary medical director review - may be considered

May be considered medically necessary when ALL of the following are met:

Secondary review criteria: A. Presenting condition is either: (1) single, abrupt episode of unexplained syncope without prodrome resulting in injury/trauma; or (2) significant, recurrent and unexplained palpitations;see text

One of the two presenting conditions required

Secondary review criteria: B. Serious cardiac arrhythmia is suspected;see text

From policy: suspicion of serious arrhythmia

Secondary review criteria: C. 30-day external ambulatory monitoring (e.g., external loop recorder) is inconclusive or contraindicated;see text

Replacement of existing ILR

Replacement may be considered medically necessary when ALL of the following are met:

Replacement criteria: All criteria for initial implantation are met AND the existing monitor is no longer functioning and is outside its warranty (e.g., device is nearing the end of its battery life).see text

Replacement requests require demonstration the device is nonfunctional and out of warranty

No explicit exclusions are listed in this portion of the clinical policy. The coding and procedural guidance sections note that inclusion or omission of specific codes in the policy does not, by itself, guarantee coverage and providers should refer to plan documents and professional coding guidance for definitive exclusion determinations.

Coverage determinations under this clinical policy are subject to the member's specific coverage documents. All terms, conditions, exclusions, and limitations contained in the member's evidence of coverage, certificate of coverage, policy, or contract of insurance apply; this policy guides medical necessity determinations but does not guarantee payment.

This policy section defines the covered indications for implantable loop recorders rather than enumerating conditions that are considered not medically necessary. Providers should consult the policy criteria for qualifying indications and submit the appropriate procedure and device codes with supporting documentation; inclusion or exclusion of codes in the policy is informational and does not by itself establish coverage.

Procedure and Device Coding

Referenced CPT CodesCPT

33285	Insertion, subcutaneous cardiac rhythm monitor, including programming.
33286	Removal, subcutaneous cardiac rhythm monitor.
93285	Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; subcutaneous cardiac rhythm monitor system.
93291	Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis.
93298	Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional.

Referenced HCPCS/G-codesHCPCS

C1764	Event recorder, cardiac (implantable).
E0616	Implantable cardiac event recorder with memory, activator, and programmer.
G2066	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results.

Provider Requirements and Administrative Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must demonstrate that the patient meets one of the medical necessity indications listed in the policy (e.g., cryptogenic stroke with suspected silent AF after inconclusive or contraindicated 30-day monitoring; suspected/known ventricular arrhythmia after inconclusive or contraindicated 30-day monitoring; high‑risk structural/infiltrative heart disease with inconclusive or contraindicated 30‑day monitoring; recurrent unexplained syncope with suspected arrhythmia and infrequent symptoms). Requests that do not meet the specified clinical criteria are at risk for denial.

Submit clinical documentation showing prior short‑term and/or long‑term ambulatory monitoring results and rationale if external monitoring was contraindicated.
Document frequency of symptoms (e.g., < once per month) when relevant and any history of structural heart disease or suspected arrhythmia.
Replacement ILR requests must document device failure or end of warranty/battery life and meet the same medical necessity criteria.

Note

Prior Authorization and Plan Procedures

Providers must follow Health Plan-level administrative policies and procedures when making coverage requests. Confirm prior authorization requirements and obtain authorization before performing services to avoid claim denials. Coverage decisions are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents.

Clinical Background

An implantable loop recorder (ILR), also called an implantable cardiac monitor (ICM), is a subcutaneous cardiac rhythm monitoring device typically implanted in the left pectoral region. These devices automatically and/or patient-activated record and store cardiac rhythm events for prolonged surveillance. Modern ILR/ICM systems are often labeled MRI-conditional and have an expected battery life of approximately 2–4 years, making them suitable for long-term evaluation of infrequent symptoms and for detection of arrhythmias such as silent atrial fibrillation after cryptogenic stroke.

Terms and Definitions

Implantable loop recorder (ILR) / implantable cardiac monitor (ICM) — Definition and key attributes

Device typeSubcutaneous monitoring device implanted in the left pectoral region (also called insertable or implantable cardiac monitor).

FunctionAutomatically or patient-activated stores cardiac rhythm events for detection of arrhythmias.

MRI statusMRI-conditional.

Battery lifeTypical battery longevity ~2–4 years (varies by manufacturer and model).

Regulatory examplesSeveral ILRs have FDA approval (e.g., Reveal LINQ, Reveal XT, Confirm Rx™, BioMonitor).

Infrequent symptoms — Definition