CurrentmhnPolicy CP.MP.113

Holter Monitors

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Medical necessity guidelines for ambulatory ECG Holter monitoring up to 48 hours for adults and pediatric members/enrollees, and indications that justify coverage; longer-term monitoring is addressed separately via clinical decision support.

Policy Summary

Payermhn

PolicyHolter Monitors

Policy CodePolicy CP.MP.113

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionFollow the listed indications to determine medical necessity for Holter monitoring up to 48 hours; refer to separate criteria for monitoring beyond 48 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-48 hoursduration of Holter monitoring addressed

≥ 2 cohorts

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CurrentmhnPolicy CP.MP.113

Holter Monitors

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Policy Summary

Payermhn

PolicyHolter Monitors

Policy CodePolicy CP.MP.113

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionFollow the listed indications to determine medical necessity for Holter monitoring up to 48 hours; refer to separate criteria for monitoring beyond 48 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-48 hoursduration of Holter monitoring addressed

≥ 2 cohorts

Medically Necessary Indications

inv-01: Adult: Medically Necessary Indications

Covered when ANY of the following adult indications are met:

Adult Holter Indications

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 non-arrhythmic cause has been identified but symptoms persist despite treatment of that 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.
Screening for asymptomatic arrhythmia in members/enrollees with Brugada syndrome.
Assessment of efficacy of medication for arrhythmia treatment when baseline arrhythmia frequency is reproducible and of sufficient frequency to permit analysis.
Detection of proarrhythmic responses to antiarrhythmic therapy in members/enrollees at high risk.
Assessment of the function of pacemakers or implantable cardioverter defibrillators (ICD) with frequent palpitations, syncope, or near-syncope, and to assist in programming of enhanced features.
Evaluation of suspected pacemaker or ICD component failure or malfunction when device interrogation is inconclusive.
Assessment of efficacy of adjunctive medications in members/enrollees receiving frequent ICD therapy.
Assessment of suspected variant angina.
Evaluation of recurrent chronic heart failure when arrhythmia is suspected.
Evaluation of possible arrhythmias post ablation procedures.

inv-02: Pediatric: Medically Necessary Indications

Covered when ANY of the following pediatric indications are met:

Pediatric Holter Indications

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.

It is the policy of health plans affiliated with Centene Corporation that Holter monitoring for any other indication not included in this policy is not medically necessary because efficacy has not been established.

Any indication not explicitly listed in the adult or pediatric criteria is considered not medically necessary for Holter monitoring up to 48 hours.

Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

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 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; I25.112; I25.702; I25.712; I25.722; I25.732; I25.752; I25.762; I25.792	Atherosclerotic heart disease and related codes (various with/without angina)
I34.0-I37.9	Nonrheumatic valvular disorders (mitral, aortic, tricuspid, pulmonary)
I42.0-I42.9	Cardiomyopathies (dilated, hypertrophic, restrictive, other)
I44.0-I45.9	Atrioventricular and bundle-branch blocks; other conduction disorders
I46.2-I49.9	Cardiac arrest, paroxysmal tachycardia, atrial fibrillation/flutter, other arrhythmias

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Authorization, Billing, and Documentation

Prior Authorization

Prior authorization / adjudication guidance for Holter (≤48 hours)

This policy provides medical necessity guidelines for Holter monitoring up to 48 hours; coverage decisions should follow the listed adult and pediatric indications. For monitoring beyond 48 hours, refer to separate clinical decision support criteria.

Use the adult and pediatric indication lists in the policy to determine medical necessity for 24–48 hour Holter monitoring.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy.

Key Definitions

Holter monitoring — definition and clinical context

DefinitionContinuous ambulatory electrocardiographic recording for a period of 24 to 48 hours used to detect arrhythmias or correlate symptoms with ECG findings.

Primary purposeEvaluation and diagnosis of cardiac arrhythmias or conduction abnormalities and correlation of symptoms (palpitations, syncope/near‑syncope, dizziness, shortness of breath, chest pain, episodic fatigue) with ECG findings.

Typical clinical utilityMost practical initial approach for patients with daily or nearly daily unexplained symptoms and for assessing efficacy of antiarrhythmic medication or other treatments.

Device capabilitiesContinuous monitoring with patient‑activated event marker to time‑stamp symptoms for correlation with recorded rhythm; allows detection of ST‑segment changes for ischemia evaluation in selected patients.

LimitationsRecording may be unhelpful if no symptoms occur during the monitoring period or if arrhythmias are present without coincident symptoms; ST‑segment changes can have nonischemic causes and must be interpreted in clinical context.

Clinical Background

Ambulatory electrocardiographic (ECG) monitoring with a Holter device records continuous cardiac electrical activity for a period of 24–48 hours to correlate patient symptoms—such as palpitations, syncope, dizziness, chest pain, dyspnea, or fatigue—with rhythm disturbances and to assess therapy or device function.