CurrentEmblemHealthPolicy N/A

Cardiac Event Monitors — Coverage Criteria and Authorization Guidance

Clinical coverage criteria and coding for external cardiac event monitors, mobile cardiovascular telemetry (MCT), and implantable loop recorders — governs prior authorization and medical necessity determinations for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyCardiac Event Monitors — Coverage Criteria and Authorization Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating the patient meets listed medical necessity criteria when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30max monitoring (days)

≤48hcontinuous ECG group

2device categories covered

5investigational devices

93241‑93248long‑term ECG codes

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External intermittent cardiac event monitors — Medically necessary

Medically necessary when ANY of the following are met:

External event monitor indications: To evaluate members with a history of cryptogenic stroke who have had a negative 24‑hour Holter or negative monitoring for 24 hours during a hospital stay.

External event monitor indications: To document benefit after initiating drug therapy for an arrhythmia.

External event monitor indications: To document recurrence of arrhythmia after discontinuation of drug therapy.

External event monitor indications: To document results after an arrhythmia ablation procedure.

External event monitor indications: To evaluate symptoms suggestive of arrhythmia (palpitations, heart racing, dizziness or syncope) when a 24‑hour Holter monitor is negative or when symptoms are documented to occur less frequently than every 24 hours.

Mobile cardiovascular telemetry (MCT) — Medically necessary

Medically necessary when evaluating recurrent unexplained presyncope, syncope, palpitations or dizziness when the following criteria (A or B) are met:

A. General MCT criteria (both required): Cardiac arrhythmia is suspected as the cause of symptoms AND the member has a non‑diagnostic Holter monitor or symptoms occur infrequently such that arrhythmia is unlikely to be diagnosed by Holter monitoring.

B. Alternative MCT indication: Evaluation of members with suspected atrial fibrillation (AF) as the cause of cryptogenic stroke who have had a nondiagnostic Holter monitor.

See applicable ICD‑10 diagnoses for cryptogenic stroke indications.

Implantable loop recorder — Medically necessary

Medically necessary for evaluation of recurrent unexplained presyncope, syncope, seizures or dizziness when ALL of the following are met:

Implantable recorder primary criteria: Cardiac arrhythmia is suspected as the cause of symptoms.

Implantable recorder prerequisite pathway: Either (a) member with heart failure, prior myocardial infarction, or significant ECG abnormalities AND noninvasive ambulatory monitoring (30‑day presymptom external recordings or MCT) has failed to establish a definitive diagnosis, OR (b) member without those conditions whose symptoms occur so infrequently and unpredictably (< once per month) that noninvasive ambulatory monitoring is unlikely to capture a diagnostic ECG.< once per month (pathway b)

Also indicated for suspected AF as a cause of cryptogenic stroke after a nondiagnostic Holter. Electrophysiology study (EPS) is not required prior to insertion.

Long-term (>48 hours) external continuous rhythm monitoring — Medically necessary

Long‑term external monitoring indications: To evaluate syncope or lightheadedness when a 24‑hour Holter is non‑diagnostic or when symptoms occur infrequently such that Holter monitoring is unlikely to diagnose the arrhythmia; or to document arrhythmia when a Holter is non‑diagnostic or symptoms are infrequent.>48 hours

Use CPT codes for monitoring durations >48 hours up to 15 days as appropriate.

Coverage criteria (code-based guidance)

Covered when diagnosis matches listed indications and monitoring is clinically indicated

Diagnostic linkage: Monitoring services (MCT or implantable loop recorder) are associated with the listed cardiac arrhythmia and neurologic ICD‑10 codes (for example: palpitations R00.2, syncope R55, dizziness R42, atrial fibrillation and cerebral infarction/TIA codes) and are intended for evaluation of suspected arrhythmia including after a nondiagnostic Holter monitor.

See ICD‑10 code listings in policy.

Procedure coding guidance: Use the applicable CPT procedure codes for the monitoring service ordered (for example, CPT 93228/93229 for MCT and CPT 33285/33286 and 93285/93291/93297/93298 for implantable loop recorder services).

See procedure code groups for exact mapping.

Coverage criteria for outpatient long-term external ECG monitoring

Covered when documentation supports use of long-term external ECG monitoring for evaluation of relevant diagnoses or symptoms and when high‑risk inpatient evaluation is not indicated:

Primary conditions: ONE of the applicable diagnoses or symptoms listed (for example: cerebral infarction/occlusion/stenosis codes, arrhythmia or conduction disorder codes, palpitations R00.2, syncope R55, abnormal ECG R94.31, history of TIA Z86.73) must be documented to justify outpatient long‑term monitoring.

See ICD‑10 lists in policy code groups.

Procedure mapping: Use CPT 93241–93248 corresponding to the monitoring duration (more than 48 hours up to 7 days or more than 7 up to 15 days) for claims and authorization.Monitoring duration >48 hours

See CPT 93241–93248.

Risk diversion: Patient should not meet short‑term high‑risk criteria that require prompt hospitalization or intensive evaluation (per ESC/EHRA/HRS guidance) prior to outpatient monitoring.

Loop recorders — whether external or implantable — are limited to the indications explicitly listed in this policy. Per the policy limitations, loop recorders are not considered medically necessary for any indications other than those listed, and requests for repeat studies within 1 year will be reviewed on a case‑by‑case basis.

Coverage is tied to the diagnoses enumerated in the policy. Although the document does not restate a blanket exclusion for every unlisted diagnosis, clinical services for monitoring may be denied if the submitted diagnosis is not among the listed indications (for example, palpitations R00.2, syncope R55, dizziness R42, or cerebrovascular diagnosis codes associated with evaluation for suspected atrial fibrillation).

Patients who meet the policy's defined short‑term high‑risk criteria should receive prompt hospitalization or intensive evaluation rather than outpatient ambulatory monitoring. Outpatient monitoring is not appropriate as the initial step for individuals with features identified by ESC/EHRA/HRS guidance that require urgent inpatient care.

The policy lists specific devices and technologies that are considered investigational and not medically necessary due to insufficient evidence. These include the AliveCor Heart Monitor (iPhoneECG), BIOTRONIK BioMonitor, BodyGuardian Remote Monitoring System, other self‑monitoring ECG technologies or the ViSi Mobile Monitoring System, and acoustic waveform recording with automated analysis (CPT 0716T).

Some sections of the policy list diagnostic codes and coverage mappings without an accompanying explicit statement labeled 'not medically necessary.' In those cases, the policy relies on the documented code lists and medical necessity criteria to determine coverage rather than separate negative phrasing.

Coding: Procedure and Diagnosis Codes

Covered CPT Codes — External & Short‑duration MonitoringCPTCovered

93224	External electrocardiographic recording up to 48 hours; includes recording, scanning analysis with report, review and interpretation
93225	External electrocardiographic recording up to 48 hours; recording (connection, recording, disconnection)
93226	External electrocardiographic recording up to 48 hours; scanning analysis with report
93227	External electrocardiographic recording up to 48 hours; review and interpretation
93268	External patient auto-activated event recording with remote download capability up to 30 days; includes transmission, review and interpretation
93270	External patient auto-activated event recording with remote download capability up to 30 days; recording
93271	External patient auto-activated event recording with remote download capability up to 30 days; transmission and analysis
93272	External patient auto-activated event recording with remote download capability up to 30 days; review and interpretation

Covered CPT Codes — Mobile Cardiovascular Telemetry (MCT)CPTCovered

93228	External mobile cardiovascular telemetry with real-time data analysis and up to 30 days surveillance; review and interpretation
93229	External mobile cardiovascular telemetry technical support, surveillance, analysis and transmission of reports
62066	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system or implantable loop recorder (tech review and distribution)

Covered CPT/HCPCS Codes — Implantable Loop Recorder Procedures & InterrogationsmixedCovered

33285	Insertion, subcutaneous cardiac rhythm monitor, including programming
33286	Removal, subcutaneous cardiac rhythm monitor
93285	Programming device evaluation (in person) for implantable loop recorder system
93291	Interrogation device evaluation (in person) with analysis for implantable loop recorder system
93297	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system
93298	Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system

Neutral ICD-10 Code Group — Selected Cerebral Infarction & Occlusion/ Stenosis ExamplesICD-10

I63.539	Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery
I63.541	Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery
I63.542	Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery
I63.543	Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries
I63.549	Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery
I63.59	Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I63.6	Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I63.81	Other cerebral infarction due to occlusion or stenosis of small artery
I63.89	Other cerebral infarction
I63.9	Cerebral infarction, unspecified

Neutral ICD-10 Code Group — Occlusion and Stenosis (precerebral/cerebral arteries)ICD-10

I65.01	Occlusion and stenosis of right vertebral artery
I65.02	Occlusion and stenosis of left vertebral artery
I65.03	Occlusion and stenosis of bilateral vertebral arteries
I65.09	Occlusion and stenosis of unspecified vertebral artery
I65.1	Occlusion and stenosis of basilar artery
I65.21	Occlusion and stenosis of right carotid artery
I65.22	Occlusion and stenosis of left carotid artery
I65.23	Occlusion and stenosis of bilateral carotid arteries
I65.29	Occlusion and stenosis of unspecified carotid artery
I65.8	Occlusion and stenosis of other precerebral arteries

1–10 of 11

1/2

Neutral ICD-10 Code Group — Occlusion and Stenosis (middle/anterior/posterior/cerebellar)ICD-10

I66.01	Occlusion and stenosis of right middle cerebral artery
I66.02	Occlusion and stenosis of left middle cerebral artery
I66.03	Occlusion and stenosis of bilateral middle cerebral arteries
I66.09	Occlusion and stenosis of unspecified middle cerebral artery
I66.11	Occlusion and stenosis of right anterior cerebral artery
I66.12	Occlusion and stenosis of left anterior cerebral artery
I66.13	Occlusion and stenosis of bilateral anterior cerebral arteries
I66.19	Occlusion and stenosis of unspecified anterior cerebral artery
I66.21	Occlusion and stenosis of right posterior cerebral artery
I66.22	Occlusion and stenosis of left posterior cerebral artery

1–10 of 15

1/2

Neutral ICD-10 Code Group — Cardiac Arrhythmia ExampleICD-10

I47.9

Paroxysmal tachycardia, unspecified / Cardiac arrhythmia unspecified (mapped example)

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for monitoring procedures listed in this policy (including MCT, implantable loop recorder insertion, long‑term external ECG monitoring CPT 93241–93248, and the procedure codes listed for MCT and implantable recorders). The treating physician or primary care provider must submit clinical evidence showing the patient meets the medical-necessity criteria; without this documentation EmblemHealth cannot properly review the request for prior authorization.

Applicable MCT procedure codes: 93228, 93229, 62066
Applicable implantable recorder procedure codes: 33285, 33286, 93285, 93291, 93297, 93298
Long-term external ECG CPTs when authorization required: 93241–93248

Denial Risk

Failure to Submit Clinical Evidence

Failure to submit the required clinical evidence and documentation will prevent proper prior authorization review and may result in denial of the request.

Denial Risk

Repeat Studies Reviewed Case‑by‑Case

Requests for repeat studies within 1 year of a previous study will be reviewed on a case‑by‑case basis and may be denied.

Documentation Required

Diagnosis and Indication Documentation Must Match

Ensure diagnosis codes on the request and claim match the supported clinical indications in this policy (examples: palpitations, syncope, dizziness/light‑headedness, history of TIA/cryptogenic stroke). Services may be denied if the submitted diagnosis is not among the listed indications.

Supported diagnostic indications include but are not limited to: palpitations (R00.2), syncope (R55* / R55 or R55.0 depending on coding), dizziness/light‑headedness (R42), history of TIA/cryptogenic stroke (Z86.73 or equivalent history code)
Cryptogenic stroke/AF evaluation indication covered when member has nondiagnostic Holter and codes for cerebral infarction/cryptogenic stroke are present

Documentation Required

Support Clinical Indication and Diagnosis Documentation

Clinical documentation should support applicable ICD‑10 diagnosis codes listed in the policy (cerebral infarction/occlusion/stenosis codes, arrhythmia and conduction disorder codes, palpitations, syncope, dizziness, convulsions where applicable). Include relevant clinical findings (symptom frequency, prior testing results such as nondiagnostic Holter or MCT) that justify the chosen monitoring modality.

Document prior noninvasive ambulatory monitoring results (e.g., nondiagnostic Holter or MCT) when implantable loop recorder is being requested
Document symptom frequency (e.g., infrequent symptoms < once per month) when arguing that external monitoring is unlikely to capture an event

Prior Authorization

Noninvasive Monitoring Prerequisite for Implantable Recorder in Some Cases

In some cases, implantation of an insertable loop recorder requires prior noninvasive ambulatory monitoring to be attempted and nondiagnostic (30‑day external recordings or MCT), or documentation that symptoms are so infrequent that noninvasive monitoring is unlikely to establish a diagnosis.

Implantable loop recorder considered when 30‑day external monitoring or MCT fails to establish diagnosis, or symptoms occur < once per month making external capture unlikely

Billing Rule

Coding and Claim Accuracy Risk

Claims must use the correct CPT procedure codes that correspond to the service authorized. Incorrect coding (e.g., failing to bill CPT 93241–93248 for long‑term external ECG monitoring or billing packaged 30‑day event services inappropriately) or insufficient documentation to support the billed service may result in claim denial.

Long‑term external ECG CPTs: 93241–93248 must be billed appropriately for services >48 hours
Cardiac event detection (30‑day packaged service) CPTs (e.g., 93268, 93270–93272) are subject to 30‑day packaging rules and may not be billed within 30 days of a prior test

Note

High‑Risk Pathway — Consider Immediate Hospitalization

Short‑term high‑risk patients (meeting criteria such as significant conduction disease, high‑burden ventricular arrhythmias, markedly reduced LVEF, syncope with concerning features, etc.) require prompt hospitalization or intensive evaluation rather than outpatient ambulatory monitoring first.

Assess for short‑term high‑risk criteria per guideline references; if present, arrange immediate inpatient evaluation rather than outpatient monitoring

Documentation Required

Provider Submission Checklist

Supporting documentation should include relevant prior test reports (e.g., Holter, MCT), clinical notes describing symptom frequency and suspected arrhythmic etiology, and the specific ICD‑10 diagnosis codes being used to justify the request. Lack of these elements increases risk of denial.

Attach nondiagnostic Holter or MCT reports when applicable
Clearly state suspected diagnosis (e.g., suspected AF after cryptogenic stroke) and reference pertinent diagnostic codes

Definitions and Device Descriptions

This policy addresses outpatient cardiac event monitoring modalities (external event monitors, mobile cardiovascular telemetry, implantable loop recorders, and long‑term external ECG monitoring) and ties coverage to documented medical necessity and diagnosis. Prior authorization requires submission of clinical evidence that the patient meets the specified indications; repeat studies within 1 year are subject to case‑by‑case review. Patients meeting short‑term high‑risk criteria per ESC/EHRA/HRS guidance should be managed with hospitalization or intensive evaluation rather than outpatient monitoring.

Cardiac event monitors

DefinitionSmall portable devices worn during normal activity for up to 30 days that record and store ECG and can be patient‑activated or use looping (pre‑symptom) memory to capture rhythms

ModesPatient‑activated (post‑symptom) or pre‑symptom looping memory; some provide automatic triggers

TransmissionSome devices support daily or immediate transmission to an attended monitoring center via phone, cellular, or internet

Mobile cardiovascular telemetry (MCT) — definition

Definition (MCT general)Non‑invasive ambulatory monitors with extended memory capable of continuous heart‑rate and rhythm measurement over several days with transmission to a remote monitoring center

FeaturesExtended memory, automatic arrhythmia detection, alarms, and remote transmission of abnormal waveforms for attended surveillance

Typical durationServices described for up to 30 days (CPT 93228–93229) with >24 hours ECG storage and remote surveillance

Mobile cardiovascular telemetry (MCT) — telemetry definition

Definition (telemetry emphasis)External telemetry with concurrent computerized real‑time analysis and ECG‑triggered and patient‑selected event transmission to an attended remote surveillance center for up to 30 days

CPT referencesSee CPT 93228 (review/interpretation) and 93229 (technical support, attended surveillance, daily/emergent reports)

PurposeProvides real‑time detection and immediate transmission of abnormal ECG for clinical review and notification

Implantable loop recorder

DefinitionSubcutaneous cardiac rhythm monitor system implanted for long‑term rhythm monitoring

Insertion/Removal CPT codesInsertion CPT 33285; removal CPT 33286

Interrogation/programming codesAssociated in‑person and remote interrogation/programming codes include CPT 93285, 93291, 93297, 93298

Long-term external ECG monitoring

DefinitionContinuous external electrocardiographic recording and storage for more than 48 hours up to 15 days

Billing/CPT groupBilled using CPT codes 93241–93248 mapped to >48 hours up to 7 days and >7 up to 15 days

Clinical useUsed when Holter is non‑diagnostic or symptoms occur infrequently such that arrhythmia is unlikely to be captured by shorter monitoring

Short‑term high‑risk criteria

DefinitionClinical features per ESC/EHRA/HRS guidance indicating need for prompt hospitalization or intensive evaluation rather than outpatient monitoring

ImplicationPatients meeting these short‑term high‑risk criteria should have inpatient/intensive evaluation rather than ambulatory outpatient monitoring

SourceESC/EHRA/HRS Task Force guidelines for diagnosis and management of syncope (2009)

OpenPayer

Cardiac Event Monitors — Coverage Criteria and Authorization Guidance

Coverage Criteria for Cardiac Monitoring Devices

Coding: Procedure and Diagnosis Codes

Provider Actions, Prior Authorization, and Documentation Requirements

Definitions and Device Descriptions

Background and Evidence References

Revision History