ModifiedUnitedHealthcarePolicy CSNCT0489.06

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

Clinical coverage criteria and background for implantable loop recorders (ILRs) and wearable cardiac rhythm monitors for North Carolina Medicaid members served by UnitedHealthcare Community Plan.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0489.06

Change TypeTitle changed; CPT code removals; evidence/reference updates

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify current applicable codes and plan-specific prior authorization requirements before billing.

SourceLink

POLICY UPDATE CHANGES

Title changed (previously titled Cardiac Event Monitoring) and definition of 'Implantable Loop Recorder' updated.

CPT codes 93224-93229, 93241-93248, 93268, 93270-93272 were removed from Applicable Codes.

Supporting Information sections (Clinical Evidence and References) were updated to reflect current information.

12.1% vs 1.8%AF detection at 12 months (STROKE-AF)

21.7% vs 2.4%AF detection at 3 years (STROKE-AF follow-up)

38.4%Pooled ILR AF detection at 36 mo

3xIncrease in AF detection (Svendsen et al.)

43.9%Diagnostic yield for unexplained syncope

1Archived prior version

Coverage Criteria for Implantable Loop Recorders and Wearable Cardiac Monitors

Initial insertion and replacement

Covered when ALL of the following are met

ILR initial insertion criteria: Noninvasive cardiac event recording is contraindicated or yielded non-diagnostic results after at least 2 weeks of monitoring AND one or more of: suspected paroxysmal atrial fibrillation in the setting of cryptogenic stroke or other documented systemic thromboembolism; suspected or known ventricular arrhythmia; high risk for arrhythmia due to structural or infiltrative heart disease (e.g., aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease, family history, dilated ischemic or nonischemic cardiomyopathy) or use of medications that prolong the QT interval; recurrent or unexplained infrequent syncope after modification of potentially causative medications or when associated with autonomic dysfunction; or abnormal diagnostic tests such as electrophysiology study or tilt‑table testing.at least 2 weeks of prior noninvasive monitoring

Replacement of an implantable loop recorder is medically necessary when the member continues to meet the initial insertion criteria and the existing device is beyond its useful life, irreparable, or no longer operating.

Guideline-based indications for extended/implantable cardiac monitoring

Covered when guideline-based clinical criteria are met (examples summarized from included guidelines):

AF/stroke monitoring after cryptogenic stroke/TIA: In patients with stroke or TIA of undetermined cause, when initial external/noninvasive cardiac monitoring is inconclusive, extended monitoring with an ILR or other long‑term monitoring is reasonable to improve detection of atrial fibrillation.after inconclusive external monitoring

Sources: ACC/AHA/ACC/ HRS, AHA/ASA, ESC, NICE

Syncope with infrequent/recurrent unexplained events: For patients with recurrent, infrequent, unexplained syncope after a nondiagnostic initial workup, long‑term ambulatory monitoring with an insertable cardiac monitor (ICM/ILR) is reasonable or indicated to detect arrhythmic causes; choice of monitoring should consider symptom frequency and prior noninvasive testing.symptoms often >30 days apart or nondiagnostic prior testing

Sources: ACC/AHA/HRS syncope guideline, HRS/ISHNE consensus

HCM rhythm surveillance: In patients with hypertrophic cardiomyopathy (HCM), initial evaluation and periodic follow‑up should include 24–48 hour ambulatory ECG; extended monitoring is recommended or considered to screen for AF in patients with palpitations, lightheadedness, or who are at high risk for AF.

The list of procedure and diagnosis codes included in this policy is provided for reference only and does not imply that a service is covered or will be reimbursed. Benefit coverage decisions are governed by applicable federal, state, or contractual requirements and laws, which may require coverage in some circumstances. Inclusion of a code in this document is not a guarantee of payment; other policies, guidelines, and plan-specific requirements may apply.

Per NICE guidance, use of an insertable cardiac monitor/implantable loop recorder such as Reveal LINQ is recommended only after prior noninvasive ECG monitoring has been performed and a cardiac arrhythmia is still suspected. ILR is not recommended as the initial test in place of appropriate noninvasive monitoring; clinicians should perform recommended ambulatory ECG monitoring (for example, 24-hour Holter or event monitoring based on symptom timing) before proceeding to ILR when feasible.

This Medical Policy is provided for informational purposes to assist interpretation of UnitedHealthcare standard benefit plans and does not constitute medical advice. Coverage determinations must follow the terms of applicable federal, state, or contractual benefit plan requirements; in the event of a conflict, those requirements govern.

Mobile health technologies and consumer wearable ECG devices are increasingly available, but guideline statements note limitations in validation and clinical performance. The ISHNE/HRS/EHRA/APHRS collaborative review and FDA materials emphasize the current status and constraints of mobile and consumer devices. Routine replacement of validated clinical monitoring devices with unvalidated consumer wearables is not supported until further evidence and regulatory guidance clarify their role.

Applicable Codes and Coding Notes

Applicable CPT / unlistedCPT

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.
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 HCPCSHCPCS

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

Removed CPT CodesCPTNot Covered

93224
93225
93226
93227
93228
93229
93241
93242
93243
93244

1–10 of 18

1/2

AF episode duration used for detection/outcome

AF episode detection threshold> 30 seconds (STROKE-AF trial primary monitoring threshold)

Study contextSTROKE-AF randomized trial monitored AF episodes >30 seconds through 12 months following ICM insertion

Monitoring duration in trialClinical and monitoring data collected at baseline, 1, 6, 12 months and continued at 6-month intervals up to 36 months or battery life

AF episode duration prompting anticoagulation (trial protocol)

AF episode prompting anticoagulation (trial protocol)≥ 6 minutes (Svendsen et al. recommendation for anticoagulation in ILR group)

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Verify prior authorization and coding

Verify prior authorization and coding requirements with the member’s specific benefit plan before scheduling ILR-related services. Policy updates may add or remove procedure codes or change code definitions; plan-level prior authorization rules and state contract requirements govern. Failure to obtain required authorization may result in claim denial.

Check plan- and state-specific prior authorization rules
Confirm current applicable CPT/HCPCS codes and edits
Obtain authorization where required prior to implantation or device-related services

Billing Rule

Code listing is not coverage guarantee

Listing of procedure, HCPCS, or diagnosis codes in this policy is provided for reference only and does not guarantee coverage or payment. Benefit determination is subject to the member’s federal, state, or contractual benefit plan and applicable laws.

Background and Clinical Context

Cardiac arrhythmias produce a spectrum of clinical presentations from isolated palpitations and lightheadedness to syncope; some arrhythmias are asymptomatic. Because symptoms may be infrequent or intermittent, accurate diagnosis often requires ambulatory ECG monitoring selected according to symptom frequency and clinical context. Implantable loop recorders (ILRs) provide long-term subcutaneous continuous monitoring and are used when noninvasive monitoring is inconclusive or when symptom cadence warrants prolonged surveillance.

Definitions

Implantable Loop Recorder

Device descriptionDevice used to detect abnormal heart rhythms; placed under the skin and continuously records the heart's electrical activity

Data transmissionRecorder can transmit data to the physician's office to help with monitoring

Clinical useMay determine why an individual is having palpitations or fainting spells, particularly if symptoms are infrequent

implantable loop recorder (ILR) / insertable cardiac monitor (ICM)

Indication summaryLong-term cardiac rhythm monitoring when noninvasive methods are inconclusive or symptoms are infrequent

Role in diagnostic pathwayConsider ILR when prolonged noninvasive monitoring is nondiagnostic after stepwise external monitoring

Policy Revision History

2025-06-01revisionLatest

Title changed from 'Cardiac Event Monitoring' to current title; definition of 'Implantable Loop Recorder' updated; multiple CPT codes were removed from Applicable Codes; Clinical Evidence and References sections updated; previous policy version CSNCT0489.05 archived.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0489.06

Change TypeTitle changed; CPT code removals; evidence/reference updates

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify current applicable codes and plan-specific prior authorization requirements before billing.

SourceLink

On This Page

periodic follow‑up every 1–2 years or with symptoms

Source: AHA/ACC HCM guideline

Device selection guided by symptom frequency: Select monitoring modality and duration based on symptom cadence: short‑term Holter (24–48 hours) for frequent episodes; patch monitors for intermediate frequency (≈7–14 days); event/loop monitors or ambulatory telemetry up to 30 days for less frequent events; consider ILR when prolonged noninvasive monitoring is nondiagnostic.based on symptom frequency

Sources: HRS/ISHNE consensus, NICE

Use of consumer wearable devices: Consumer wearable heart‑monitoring devices are increasingly used but require further validation; they should not routinely replace validated clinical monitoring pathways until accuracy and appropriate clinical roles are better defined.validation needed

Source: ACC/AHA/ACCP/HRS guideline statements

Participants 70–90 years old with ≥1 additional stroke risk factor; randomized to ILR vs usual care

Primary outcomeTime to first stroke or systemic arterial embolism with median follow-up 64.5 months

Code lists are not all-inclusive
Inclusion of a code does not imply coverage or reimbursement

Documentation Required

Prior noninvasive monitoring expected

Noninvasive ECG monitoring is expected and should generally be performed prior to ILR insertion when clinically appropriate. Document attempts, duration, and results of prior noninvasive monitoring (e.g., Holter, patch, MCOT, event recorder).

Record type of monitor(s) used, monitoring duration, and diagnostic outcome
If noninvasive monitoring was contraindicated, document the clinical reason

Note

Coverage must be determined in the context of federal, state, or contractual requirements

Coverage determinations must be made in the context of applicable federal, state, or contractual benefit plan requirements; where these differ from this Medical Policy, the federal/state/contractual requirements govern.

Resolve conflicts by following the applicable federal, state, or contractual terms
Check for plan-specific amendments or coverage mandates

Documentation Required

Support initial criteria for ILR insertion

Support initial criteria for ILR insertion with documentation showing noninvasive monitoring was contraindicated or nondiagnostic after an appropriate trial (typically at least 2 weeks when indicated), and that the clinical indication meets one of the policy-listed circumstances (e.g., cryptogenic stroke with suspected AF, unexplained infrequent syncope, suspected ventricular arrhythmia, high arrhythmia risk due to structural disease).

Document symptom frequency and why shorter-duration monitoring was insufficient
Include prior test results (ECG, Holter, MCOT, event monitor), reports, and clinical rationale

Documentation Required

Support for ILR replacement

For replacement of an ILR, document that the member continues to meet all initial insertion criteria and that the existing device is beyond its useful life, irreparable, or no longer functioning.

Provide device interrogation/report showing device failure or end of service
Document ongoing clinical indication that justifies replacement

Note

Before using this policy, check federal, state or contractual requirements

Before relying on this Medical Policy for a coverage decision, check the applicable federal, state, or contractual benefit plan requirements and any third-party criteria UnitedHealthcare may use (e.g., InterQual). This policy is informational and may be superseded by plan-specific rules.

Review plan documents and state mandates
Confirm whether UnitedHealthcare uses third-party criteria for the case

Step Therapy

Consider noninvasive monitoring before ILR

Consider noninvasive monitoring modalities (e.g., MCOT, patch monitors, ambulatory telemetry) before proceeding to an ILR when the patient is able to comply and symptom frequency suggests a reasonable chance of detection with extended external monitoring.

MCOT may detect a significant proportion of AF within one month and can be preferred when patient can comply
If MCOT is negative after an adequate trial (e.g., ~4 weeks) or compliance is a concern, ILR may be considered

Step Therapy

Stepwise monitoring approach

Use a stepwise monitoring approach guided by symptom frequency: start with short-term continuous ambulatory monitoring (24–7 days), progress to intermittent external loop/event recording or longer ambulatory monitors (up to 30 days) as indicated, and reserve ILR for individuals who remain undiagnosed after prolonged noninvasive monitoring or when long-term continuous subcutaneous monitoring is clearly indicated.

Short-term (24–48 hours) Holter or 7–14 day patch monitors for frequent symptoms
30-day ambulatory or event monitors / MCOT for less frequent symptoms
ILR for persistent suspicion after prolonged noninvasive monitoring or when events are extremely infrequent

Note

Provider action items and reminders

Before ordering or billing for ILR services, verify the member’s benefit plan requirements, document prior monitoring and clinical rationale, and confirm whether prior authorization is required. UnitedHealthcare may use external criteria to adjudicate medical necessity.

Document prior noninvasive monitoring attempts and symptom frequency
Confirm coding and billing aligned with current code set and plan rules

Symptom-frequency guidanceFrequency of symptoms should guide monitor selection; longer-term monitoring for more infrequent events

Implantable Loop Recorder — definition update

Definition changeDefinition of 'Implantable Loop Recorder' was updated in the 06/01/2025 policy revision

Policy update noteTitle changed from 'Cardiac Event Monitoring' and applicable CPT codes were removed in this revision

DocumentationSee Policy History/Revision Information for details and archived previous version CSNCT0489.05