CurrentUnitedHealthcarePolicy CS092KY.11

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

UnitedHealthcare Community Plan medical policy for the state of Kentucky addressing medical necessity criteria for implantable loop recorders (ILRs) and coverage determination for wearable/cardiac self-monitoring devices, including age-specific indications and replacement criteria, and lists applicable procedure and HCPCS codes.

Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS092KY.11

Change TypeRevised / Added / Removed

Effective DateJune 1, 2025

Next Review Date

Key ActionDocument that medical necessity criteria per InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG) are met for adults and for pediatric members document prior noninvasive monitoring (≥2 weeks) and the specific pediatric indication before proceeding to ILR.

SourceLink

POLICY UPDATE CHANGES

Policy title changed from 'Cardiac Event Monitoring (for Kentucky Only)' to focus on Implantable Loop Recorders.

Clarified noncoverage: wearable heart rhythm monitors and cardiac self-monitoring devices commercially available to the general public and purchased for home use are not medically necessary.

Added pediatric ILR criteria for members under 18 years of age with specific indications.

Removed multiple CPT codes related to external cardiac monitoring (list provided).

Added CPT code 33286 for Implantable Loop Recorder.

Updated Clinical Evidence and References sections to reflect current information.

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Coverage Summary

UnitedHealthcare Community Plan (Kentucky) policy CS092KY.11 (effective June 1, 2025) covers Implantable Loop Recorders (ILRs) and wearable/cardiac self-monitoring devices for members in Kentucky. The policy states that ILRs are proven and medically necessary in certain circumstances (with adult clinical coverage criteria per InterQual) and includes age-specific indications and replacement criteria. In contrast, consumer wearable or cardiac self-monitoring devices commercially available to the general public and purchased for home use are not medically necessary. The policy number is CS092KY.11.

Quick thresholds & facts

Noninvasive monitoring prior to ILRAt least two weeks

State applicabilityKentucky

Pediatric ILR indications added5

CPT codes removed20

New CPT added33286

Medical Necessity Criteria

Members 18 Years of Age and Older — Implantable Loop Recorders

Implantable Loop Recorders are proven and medically necessary in certain circumstances; refer to InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG) for medical necessity clinical coverage criteria.

ALL of the following

Member is 18 years of age or older
Medical necessity clinical coverage criteria per InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG) are met
Policy references InterQual criteria for adults

Members Under 18 Years of Age — Implantable Loop Recorders

Implantable Loop Recorders are proven and medically necessary for evaluating suspected cardiac arrhythmias when noninvasive cardiac event recording is contraindicated or yielded non-diagnostic results after at least two weeks of monitoring in one or more of the following circumstances:

ONE or more of

Not Medically Necessary / Consumer Devices

Cardiac Self-Monitoring Devices (All Ages)

Consumer-grade wearable heart rhythm monitors and cardiac self-monitoring devices commercially available to the general public and purchased for home use are not medically necessary.

ALL of the following

Device is a consumer-grade cardiac self-monitoring device or wearable commercially available to the general public and purchased for home use
Device intended for self-monitoring/detection of heart rhythm (examples include: ECG monitor combined with a cellular telephone or watch; hardware/software required for downloading ECG data to a personal computer, tablet, or smart phone)
Examples listed in policy

Rationale: ILRs are supported as proven and medically necessary when indicated because they provide extended, implantable rhythm monitoring that can detect arrhythmias not captured by shorter noninvasive monitoring; for adults the policy defers to InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG) for specific medical necessity criteria. By contrast, consumer-grade wearable heart rhythm monitors and cardiac self-monitoring devices intended for home use are explicitly not medically necessary due to insufficient evidence of efficacy and are considered convenience items.

Coding

Implantable Loop Recorder — CPT/HCPCS/OthermixedCovered

0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device...
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; subcutaneous cardiac rhythm monitor system.
93291	Interrogation device evaluation (in person) with analysis, review and report; subcutaneous cardiac rhythm monitor 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; subcutaneous cardiac rhythm monitor system...
E0616	Implantable cardiac event recorder with memory, activator, and programmer.

Cardiac Self-Monitoring Devices — CPT/HCPCS/UnlistedmixedNot 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.
E1399	Durable medical equipment, miscellaneous.

Removed CPT codesCPT

93224
93225
93226
93227
93228
93229
93241
93242
93243
93244

1–10 of 18

1/2

Added CPT code - Implantable Loop RecorderCPTCovered

33286

Implantable loop recorder insertion

Provider Actions

Documentation Required

Reference InterQual criteria for adults

Document that medical necessity per InterQual AECG is met for members 18 years and older. Include reference to the InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG) criteria when charting the indication for ILR insertion and retention.

Documentation Required

Document prior noninvasive monitoring for pediatric members

For pediatric members (<18 years), document at least 2 weeks of noninvasive ambulatory cardiac event monitoring that was nondiagnostic or contraindicated prior to ILR insertion. Documentation must specify duration (≥2 weeks) and one or more of the following pediatric indications: suspected paroxysmal atrial fibrillation in the setting of cryptogenic stroke or systemic thromboembolism; suspected or known ventricular arrhythmia; high risk for arrhythmia due to structural or infiltrative heart disease (e.g., hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease, dilated cardiomyopathy), medication-induced malignant arrhythmia risk (e.g., QT-prolonging drugs); recurrent or unexplained infrequent syncope after medication modification or associated with autonomic dysfunction; or abnormal electrophysiology study or tilt-table test results.

Background and Evidence

Background and evidence summary: ILRs are implanted subcutaneously to continuously record the heart's electrical activity and transmit data to clinicians to help determine causes of infrequent palpitations or syncope. The choice of ambulatory ECG modality and monitoring duration is dictated by symptom frequency. Evidence includes systematic reviews, randomized trials, and guideline recommendations showing higher arrhythmia and atrial fibrillation detection rates with long-term implantable monitoring (for example, higher AF detection with ICM/ILR versus usual care in randomized trials and pooled detection rates over months to years). Studies report improved diagnostic yield for unexplained syncope and increased AF detection after stroke with ILRs, though impact on downstream clinical outcomes like recurrent stroke remains uncertain in some trials. InterQual criteria are referenced for adult medical necessity determinations.

Evidence — detection/yield metrics

STROKE-AF 12-month AF detectionICM 12.1% vs control 1.8%; HR 7.4 (95% CI 2.6-21.3)

STROKE-AF 3-year AF detectionICM 21.7% vs control 2.4%

Jiang et al. pooled AF rates (ILR)4.9% at 1 month to 38.4% at 36 months

Solbiati et al. diagnostic yield (unexplained syncope)

Revision History

2025-06-01title_changeLatest

Policy title changed from 'Cardiac Event Monitoring (for Kentucky Only)' to 'Implantable Loop Recorders and Wearable Heart Rhythm Monitors (for Kentucky Only)' (CS092KY.11).

2025-06-01coverage_revisionLatest

Replaced broad language about cardiac event monitoring with specific statements that Implantable Loop Recorders (ILRs) are proven and medically necessary in certain circumstances for adults; defers adult clinical coverage criteria to InterQual CP: Procedures, Electrocardiography, Ambulatory (AECG).

Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS092KY.11

Change TypeRevised / Added / Removed

Effective DateJune 1, 2025

Next Review Date

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 such as 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 such as those prolonging the QT interval
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

Members Under 18 Years of Age - Added Criteria (Implantable Loop Recorders)

Implantable Loop Recorders are proven and medically necessary when noninvasive cardiac event recording is contraindicated or yielded non-diagnostic results after at least two weeks of monitoring, AND one or more of the following are present:

ALL of the following

ONE OR MORE OF
- 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 such as 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 such as those prolonging the QT interval
- 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

Prior Authorization

Replacement device prior authorization

Obtain prior authorization for replacement implantable loop recorders (ILR) when replacement is requested. Replacement is considered medically necessary only when the member continues to meet initial insertion criteria and the existing device is beyond its useful life, irreparable, or no longer operating. When submitting authorization requests for replacement ILR procedures, include supporting documentation that the member still meets initial criteria and reason for replacement.

Prior authorization required for replacement ILR
CPT 33286 (removal) — reference when applicable

Denial Risk

Consumer wearable devices not covered

Claims for consumer wearable or self-monitoring cardiac devices purchased for home use (consumer-grade mobile ECGs, smartwatches with ECG, or associated hardware/software for data download) are not medically necessary and are subject to denial. These items are considered convenience devices and lack sufficient evidence of efficacy for medical management.

Examples include self-monitoring ECG combined with phone/watch, and hardware/software for downloading ECG data to personal devices

Definitions: Implantable Loop Recorder (ILR): Device placed subcutaneously that continuously records heart electrical activity and can transmit data to a physician to help determine causes of infrequent palpitations or fainting spells. Cardiac Self-Monitoring Devices: Consumer-grade, connected electronic devices and/or software applications used without a physician's prescription to collect physiologic information (e.g., ECG) downloadable to personal devices; wearable heart rhythm monitors or devices combining ECG with a phone or watch and associated hardware/software for data download are included. ILR (synonym): Insertable/Implantable Loop Recorder for long-term cardiac rhythm monitoring.

2025-06-01pediatric_criteria_addedLatest

Added pediatric ILR criteria: ILRs are medically necessary for members under 18 when noninvasive monitoring was contraindicated or nondiagnostic after at least two weeks of monitoring and one or more indications are present (suspected paroxysmal AF after cryptogenic stroke or thromboembolic event; suspected/known ventricular arrhythmia; high arrhythmia risk from structural/infiltrative disease; recurrent unexplained infrequent syncope after medication modification or with autonomic dysfunction; abnormal EP or tilt testing).