CurrentUnitedHealthcarePolicy CSNCT0489.06

Implantable Loop Recorders and Wearable Heart Rhythm Monitors (for North Carolina Only)

UnitedHealthcare Community Plan medical policy (North Carolina only) defining medical necessity criteria for implantable loop recorders (ILR) and related cardiac rhythm monitoring devices, replacement criteria, applicable procedure/HCPCS/CPT codes, supporting evidence and guideline references. This is part 1 of 2.

Policy Summary

PayerUnitedHealthcare

PolicyImplantable Loop Recorders and Wearable Heart Rhythm Monitors (for North Carolina Only)

Policy CodePolicy CSNCT0489.06

Change TypeTitle, definitions, applicable codes, evidence updates

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider must document that noninvasive cardiac event recording was contraindicated or yielded non-diagnostic results after at least 2 weeks of monitoring prior to ILR insertion.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Cardiac Event Monitoring (for North Carolina Only)' to the current title.

Definition of 'Implantable Loop Recorder' updated.

CPT codes 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, and 93272 removed from Applicable Codes.

Supporting Information: Clinical Evidence and References sections updated to reflect the most current information.

Previous policy version CSNCT0489.05 archived.

5Listed primary clinical indications

8Key CPT/HCPCS codes referenced

Coverage Summary

Scope: This policy is the UnitedHealthcare Community Plan medical policy for North Carolina only, defining medical necessity criteria for implantable loop recorders (ILR) and related cardiac rhythm monitoring devices, replacement criteria, applicable procedure/HCPCS/CPT codes, supporting evidence and guideline references. (Part 1 of 2.)

Background: Implantable loop recorders are subcutaneous devices placed under the skin that continuously record the heart's electrical activity and can transmit data to a physician to help monitor for abnormal heart rhythms. Selection of monitoring modality is dictated by symptom frequency; ILRs are indicated when noninvasive tests are contraindicated or nondiagnostic after appropriate noninvasive monitoring and for prolonged monitoring needs. Key clinical indications include: suspected paroxysmal atrial fibrillation in the setting of cryptogenic stroke or other systemic thromboembolism, recurrent or unexplained infrequent syncope, and suspected arrhythmia in patients at high risk because of structural or infiltrative heart disease (examples: aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease, dilated ischemic or nonischemic cardiomyopathy) or use of QT-prolonging medications.

Policy metadata

Policy numberCSNCT0489.06

Effective date2025-06-01

Last review2025-06-01

StatusCURRENT

ScopeNorth Carolina only

Policy Version (current)1

Medically Necessary Criteria

Medically Necessary: Implantable Loop Recorder (ILR) insertion

Implantable Loop Recorders are proven and medically necessary when ALL of the following are met:

ALL of the following

Indications (ONE or more of the following)
- Noninvasive cardiac event recording is contraindicated or yielded non-diagnostic results after at least 2 weeks of monitoring
  Provider must document that noninvasive monitoring was contraindicated or nondiagnostic after ≥2 weeks prior to ILR insertion.
- Suspected paroxysmal atrial fibrillation in the setting of a cryptogenic stroke or another documented systemic thromboembolic event
- Suspected or known ventricular arrhythmia

Coding

Covered / referenced CPT codes for ILR and related servicesCPTCovered

33285	Insertion, subcutaneous cardiac rhythm monitor, including programming
33286	Removal, subcutaneous cardiac rhythm monitor
93285	Programming device evaluation (in person) with iterative adjustment; subcutaneous cardiac rhythm monitor system
93291	Interrogation device evaluation (in person) with analysis, includes connection, recording and disconnection; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis
93297	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of recorded physiologic cardiovascular data elements, analysis, review(s) and report(s)
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)
93799	Unlisted cardiovascular service or procedure

Referenced CPT codes not on NC Medicaid fee schedule (may not be covered by NC Medicaid)CPT

0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system with iterative adjustment and physician review/report (not on NC Medicaid fee schedule)
0902T	QTc interval derived by augmentative algorithmic analysis of input from an external, patient-activated mobile ECG device (not on NC Medicaid fee schedule)

HCPCS / DME codesHCPCS

E0616	Implantable cardiac event recorder with memory, activator, and programmer
E1399	Durable medical equipment, miscellaneous

Removed CPT codes (as of 2025-06-01)CPT

93224
93225
93226
93227
93228
93229
93241
93242
93243
93244

1–10 of 18

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Provider Actions & Documentation Requirements

Documentation Required

Document prior noninvasive monitoring

Provider must document that noninvasive cardiac event recording was contraindicated or yielded non-diagnostic results after at least 2 weeks of monitoring prior to implantable loop recorder insertion.

Documentation Required

Document indication(s)

Provider must document the specific indication that meets policy criteria: suspected paroxysmal atrial fibrillation in the setting of a cryptogenic stroke or other systemic thromboembolic event; suspected or known ventricular arrhythmia; high risk for arrhythmia due to structural or infiltrative heart disease (for example aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease, family history, dilated ischemic or nonischemic cardiomyopathy) or use of medications known to cause malignant arrhythmias (e.g., QT-prolonging drugs); recurrent or unexplained infrequent syncope after modification of potentially causative medications or syncope associated with autonomic dysfunction; or abnormal tests such as electrophysiology study or tilt table testing.

Background & Supporting Evidence

ILRs are implantable, subcutaneous cardiac monitors that continuously record ECG data and transmit recordings for physician review. They are used when longer-term monitoring is needed or when noninvasive ambulatory monitoring (Holter, patches, external/event monitors) is nondiagnostic or not appropriate based on symptom frequency and clinical context.

This policy applies only to North Carolina and aligns ILR use with the principle that monitoring modality and duration should match symptom frequency; ILRs are reserved for prolonged monitoring needs or when noninvasive options have failed or are contraindicated.

Evidence / Guideline	Key finding
STROKE-AF trial (Bernstein et al., 2021/2023)
ICM detected significantly more AF vs usual care: 12-month AF detection 12.1% vs 1.8%; 3‑year detection 21.7% vs 2.4%.
PER DIEM trial (Buck et al., 2021)
ILR 12‑month AF detection 15.3% vs external loop recorder 4.7%.
Systematic reviews/meta-analyses (Jiang 2022; Noubiap 2021)
Pooled AF detection with ILR increases over time (examples: 4.9% at 1 month to ~38.4% at 36 months; Noubiap pooled rates: 12.2% at 3 months to 28.5% at 36 months); MCOT/MCOT-like devices may detect more AF earlier (higher 1-month detection).
Syncope diagnostic yield (Solbiati 2017)
Overall diagnostic yield of ILR for unexplained syncope ~43.9% (95% CI 40.2%–47.6%); ILR strategy superior to conventional follow-up in detecting relevant arrhythmias.
Key guideline references updated (AHA/ACC/ESC/ESO/NICE/HRS/others)
Guidelines support using ILR for cryptogenic stroke when external monitoring is inconclusive, for infrequent/recurrent unexplained syncope after nondiagnostic workup, and to improve AF detection in selected high‑risk patients; recommendations note prolonged monitoring increases AF detection and that noninvasive options may be reasonable initial steps.

Definitions

Implantable Loop Recorder: Device placed under the skin that continuously records the heart's electrical activity and can transmit data to the physician to help monitor for abnormal heart rhythms.

Note: The policy's Definitions section was updated to revise the Implantable Loop Recorder definition.

Revision History

06/01/2025title_changeLatest

Policy title updated from 'Cardiac Event Monitoring (for North Carolina Only)' to 'Implantable Loop Recorders and Wearable Heart Rhythm Monitors (for North Carolina Only)'.

06/01/2025definition_updateLatest

Definitions section updated to revise the Implantable Loop Recorder definition (device placed under the skin that continuously records cardiac electrical activity and can transmit data).

06/01/2025