CurrentUnitedHealthcarePolicy CS092ID.B

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

State-specific UnitedHealthcare medical policy applicable only to Idaho (including Idaho Medicaid Plus) describing coverage positions for implantable loop recorders (referencing Idaho Medicaid Handbook) and non-state-specific criteria addressing cardiac self-monitoring (consumer-grade wearable) devices.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS092ID.B

Change TypeRevision with removed coverage language and Idaho-specific instruction added

Effective DateDecember 1, 2025

Next Review Date

Key ActionFor implantable loop recorder medical necessity criteria, providers must follow the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor.

SourceLink

POLICY UPDATE CHANGES

Title changed (previously titled 'Cardiac Event Monitoring (for Idaho Only)') and state-specific criteria instruction updated to reference Idaho Medicaid handbook.

Policy title changed from 'Cardiac Event Monitoring (for Idaho Only)' to current title and Idaho-specific instructions added.

Removed language indicating several ambulatory monitoring modalities and ILRs were proven and medically necessary for evaluating suspected cardiac arrhythmias.

Updated Description of Services, Clinical Evidence, and References sections to reflect current information and archived prior policy version CS092ID.A.

1State-specific policy (Idaho only)

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Consumer wearable devices: covered indications

1State-specific ILR criteria (external)

1Material changes noted

2025-12-01Policy effective date

Coverage Summary

This policy is a state-specific UnitedHealthcare coverage document that applies only to Idaho (including Idaho Medicaid Plus) and addresses implantable loop recorders (ILRs) and wearable heart rhythm monitors. The coverage stance is mixed: ILR clinical medical necessity criteria are not restated here but are directed to the external Idaho Medicaid Provider Handbook (Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor), while consumer-grade cardiac self-monitoring devices are identified as not medically necessary. The policy is effective December 1, 2025. For ILR coverage determinations, providers must follow the Idaho Medicaid handbook referenced in the policy rather than the removed in-policy ILR indications.

Policy key items

Policy numberCS092ID.B

SubjectImplantable Loop Recorders and Wearable Heart Rhythm Monitors (Idaho only)

ScopeIdaho only (includes Idaho Medicaid Plus)

Effective dateDecember 1, 2025

Coverage stanceMixed (state-specific ILR criteria referenced externally; consumer-grade self-monitoring devices not medically necessary)

Has material changeYes (policy notes material removals and additions; instruction to refer to Idaho Medicaid handbook added)

Medical-Necessity Criteria

Application / State-specific criteria

This policy applies only in Idaho; implantable loop recorder medical necessity criteria are in an external Idaho Medicaid handbook:

ALL of the following

Policy applies only to the state of Idaho, including Idaho Medicaid Plus plans
For medical necessity clinical coverage criteria for implantable loop recorders, refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor

Non-State Specific Criteria (excerpted changes)

Removal statement describing previously considered medically necessary uses:

ALL of the following

Previously listed ILR indications (removed)

Coding

Implantable Loop Recorder / insertions and removals / programming / interrogationsmixed

0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professional.
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.
93297	Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional.
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.
93799	Unlisted cardiovascular service or procedure

Cardiac Self-Monitoring Devices (consumer-grade) / device HCPCSHCPCSNot Covered

E0616	Implantable cardiac event recorder with memory, activator, and programmer.
E1399	Durable medical equipment, miscellaneous (listed here for Cardiac Self-Monitoring Devices reference)

Cardiac Self-Monitoring Devices / CPT referencesCPTNot Covered

0902T	QTc interval derived by augmentative algorithmic analysis of input from an external, patient-activated mobile ECG device.
93799	Unlisted cardiovascular service or procedure

Applicable Codes (section header present; specific codes not listed in this part)mixed

No codes listed

Provider Actions

Documentation Required

Refer to Idaho Medicaid Handbook for ILR medical necessity

For implantable loop recorder medical necessity criteria, providers must follow the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor (external reference).

Denial Risk

Consumer-grade cardiac self-monitoring devices not medically necessary

Claims for consumer-grade wearable cardiac self-monitoring devices and associated hardware/software purchased for home use are considered convenience items and are not medically necessary due to insufficient evidence of efficacy; such claims may be denied.

E1399
0902T
93799

Background and Evidence

Ambulatory ECG monitoring encompasses a range of modalities (short-term Holter, patch monitors, event/loop monitors, ambulatory telemetry, and insertable cardiac monitors/ILRs), and the type and duration of monitoring should be dictated by symptom frequency (for example, shorter-term monitoring for daily symptoms and longer-term or implantable monitoring for infrequent events). Consumer-grade, wearable cardiac self-monitoring devices and related hardware/software that download ECG data to personal devices are considered convenience items, lack sufficient high-quality evidence of clinical benefit, and are not medically necessary. Clinical studies and reviews (including randomized trials and meta-analyses) show variable accuracy, unclassified/false-positive rates, adherence issues, and unclear impact on patient outcomes, supporting the policy position that these consumer devices are unproven for routine medical use.

Study / Source	Key finding
Pulsewatch RCT (Ding et al. 2023)	Smartwatch system demonstrated 92.9% accuracy for AF detection in older adults post-stroke; small sample and short duration; adherence concerns (mean wear 21.2 of 30 days).
Meta-analysis (Manetas-Stavrakakis et al. 2023)	Pooled sensitivity/specificity: PPG 95.1%/96.2%; single-lead ECG 92.3%/96.2%; unclassified tracing rates variable (0–43.2% PPG, 0–38% ECG); further research needed on clinical outcomes.
Hayes Evolving Evidence Review (2021, updated 2023)	No clear support for clinical utility of mobile medical applications to improve patient health outcomes; evidence limited by small studies and inadequate follow-up.
Koh et al. RCT (2021)	30-day smartphone single-lead ECG detected more AF (9.5%) vs 24-hour Holter (2%); high unclassified (13.1%) and false-positive rates (>75% of 'possible AF' were false positives); generalizability uncertain.
Apple Heart Study (Perez et al. 2019)	Of participants receiving an irregular pulse notification who returned ECG patches, 34% had AF on patch; overall notification rate low (0.52%); study limited by low patch return, loss to follow-up, selection biases.
ACC/AHA/ACCP/HRS and other guideline statements	Guidelines support use of ambulatory monitoring and ILRs for detection of AF in selected patients (eg, cryptogenic stroke, infrequent symptoms) and note need for validation and definition of best use for consumer wearables.

Definitions (quick reference)

Cardiac Self-Monitoring DevicesConsumer-grade connected devices and software usable without a physician's prescription that collect physiologic information (e.g., ECG) downloadable to personal devices; considered convenience items and not medically necessary

Medical PolicyProvides assistance in interpreting UnitedHealthcare standard benefit plans but does not constitute medical advice; federal/state/contractual requirements govern if conflicting

Revision History

12/01/2025revised

Title changed (previously titled 'Cardiac Event Monitoring (for Idaho Only)') and state-specific criteria instruction updated to reference Idaho Medicaid Provider Handbook.

12/01/2025revisedLatest

Instruction added directing readers to refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor for medical necessity clinical coverage criteria for implantable loop recorders.

12/01/2025

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS092ID.B

Change TypeRevision with removed coverage language and Idaho-specific instruction added

Effective DateDecember 1, 2025

Next Review Date

Key ActionFor implantable loop recorder medical necessity criteria, providers must follow the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor.

SourceLink

On This Page

Suspected paroxysmal atrial fibrillation in the setting of a cryptogenic stroke or another documented systemic thromboembolic event.

Suspected or known ventricular arrhythmia.

High risk for arrhythmia secondary to structural or infiltrative heart disease (examples: aortic stenosis; hypertrophic cardiomyopathy; cardiac sarcoidosis; congenital heart disease; family history; dilated ischemic or nonischemic cardiomyopathy; use of medications known to cause malignant arrhythmias such as QT-prolonging drugs).

Recurrent or unexplained infrequent syncope after modification of potentially syncope-causing medications or associated with autonomic dysfunction.

Abnormal tests such as electrophysiology study or tilt table testing.

Replacement of implantable loop recorders was previously considered medically necessary when the individual continues to meet all initial criteria and the existing device is beyond its useful life span, irreparable, or no longer operating.

Previously, ambulatory event monitoring (Holter, event, patch-type) and outpatient cardiac telemetry were considered proven and medically necessary for evaluating suspected cardiac arrhythmias — this language was removed (no longer stated as proven/medically necessary).

Non state-specific criteria: Cardiac Self-Monitoring Devices

Wearable consumer-grade cardiac self-monitoring devices are not medically necessary:

ALL of the following

Examples (not limited to)
- A self-monitoring device that includes an ECG monitor combined with a personal electronic device such as a cellular telephone or watch
- Hardware or software required for downloading ECG data to a device such as personal computer, tablet, or smart phone

Definition: Cardiac Self-Monitoring Devices: Consumer-grade, connected electronic devices and/or software applications usable without a physician's prescription that collect physiologic information (e.g., ECG) downloadable to personal devices; considered convenience items and not medically necessary.

Idaho-Specific Criteria Direction (added)

Instruction added directing readers to Idaho Medicaid Provider Handbook for ILR clinical coverage criteria:

Refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8: Subcutaneous Cardiac Rhythm Monitor for medical necessity clinical coverage criteria for implantable loop recorders.

Documentation Required

Refer to state-specific handbook for ILR criteria (Idaho)

For Idaho members, providers must refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.8 for the medical necessity clinical coverage criteria for implantable loop recorders.

Removed language indicating ambulatory event monitoring (Holter, event, patch-type), outpatient cardiac telemetry, and that implantable loop recorders and their replacement criteria were proven and medically necessary for evaluating suspected cardiac arrhythmias.

revised

Supporting Information updated; Description of Services, Clinical Evidence, and References sections refreshed and prior policy version CS092ID.A archived.