Ambulatory Cardiac Event Monitors
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Policy governing coverage, definitions, prior authorization, and coding guidance for ambulatory cardiac event monitors for Geisinger Health Plan members across applicable lines of business.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Coverage with Prior Authorization and Benefit Determinations
Covered when the following prior authorization and benefit determination requirements are met:
Cohere uses proprietary clinical criteria, Utilization Management decision‑support tools, and evidence‑based medical treatment guidelines; provider should verify member-specific benefits and line-of-business rules which supersede this policy.
For PA Medicaid business segment, this policy applies as written.
Refer to the policy coding section for example MCT codes (e.g., CPT 93228, 93229) and to Cohere for prior authorization procedures.
Providers should obtain prior authorization at https://www.geisinger.org/health-plan/providers/ghp-clinical-policies or the Cohere platform.
Coverage for experimental or investigational treatments, services, and procedures is specifically excluded under the member's certificate with Geisinger Health Plan. Unproven services provided outside of an approved clinical trial are also specifically excluded. This policy does not expand coverage to services or items that are expressly excluded in the member’s certificate; see MP015 for additional information on experimental, investigational, or unproven services.
The inclusion of a procedure or device code in this policy is for informational purposes only and does not constitute or imply coverage or guarantee provider reimbursement. Coverage is determined by the member-specific benefit plan document and any applicable laws or Medicare rules. Per Medicare guidance, only specific CPT/HCPCS codes may be covered for the Medicare business segment; consult the CMS website or the local Medicare Administrative Contractor for Medicare coding and coverage details.
Relevant Procedure Codes
| 93228 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and >24 hours of accessible ECG data storage; 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 >24 hours of accessible ECG data storage; technical support, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed |
Provider Requirements and Billing Actions
Obtain prior authorization via Cohere
Prior authorization through Cohere is required for Cardiology services (including ambulatory cardiac event monitors) for members enrolled in Geisinger Health Plan Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products. Cohere uses proprietary clinical criteria and UM decision‑support tools to determine approval. Providers must obtain authorization via the Cohere platform before providing these Cardiology services.
- Applies to specified Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products
- Cohere applies proprietary clinical criteria and utilization management decision‑support tools
Confirm member eligibility and contract‑specific benefits
Verify member eligibility and benefits before ordering services and document any plan‑specific requirements; benefits and coverage are determined by the member’s contract and line‑of‑business rules. Failure to confirm eligibility or contract‑specific coverage may affect authorization and payment.
- Eligibility and contract‑specific benefits, limitations and exclusions will apply
- Line of business benefit documents supersede this policy
Document per member benefits and Medicare LCD/NCDs; CPT/HCPCS are informational
Include documentation that aligns with the member’s specific benefit plan and any applicable Medicare Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs). CPT/HCPCS codes listed in the policy are informational only and do not guarantee coverage or reimbursement.
- Documentation should match member‑specific benefit documents and applicable Medicare LCD/NCDs
- Inclusion of CPT/HCPCS codes in the policy is informational and does not imply coverage
Risk of denial if Cohere prior authorization is missing
Services provided without prior authorization through Cohere may be denied; eligibility and contract‑specific benefits, limitations and exclusions will also influence coverage determinations and may supersede this policy.
- Lack of Cohere prior authorization may trigger denial
- Eligibility and contract‑specific benefits and limitations supersede the policy when applicable
Background and Context
Ambulatory event monitors are wearable recording devices that provide extended cardiac monitoring by continuously or intermittently recording electrocardiograms (ECGs) which are stored for later analysis or transmitted for remote review. Devices may be patient‑activated or automatically triggered, and technology ranges from event recorders that store tracings to mobile cardiovascular telemetry (MCT) systems that perform concurrent computerized real‑time data analysis and remote transmission for up to 30 days. MCT systems support >24 hours of accessible ECG data storage and can include attended surveillance with analysis and transmission of daily and emergent reports.
Definitions
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