Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry

Medical Policy: 02.02.11 
Original Effective Date: April 2006 
Reviewed: October 2011 
Revised: July 2010 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Ambulatory event monitors (AEMs) were developed to provide longer periods of monitoring. In this technique the recording device is either worn continuously and activated only when the patient experiences symptoms or is carried by the patient and applied and activated when symptoms are present. The recorded EKGs are then stored for future analysis or transmitted by telephone to a receiving station, such as a doctor's office, hospital, or cardiac monitoring service, where the EKGs can then be analyzed. AEMs can be used for extended periods of time, typically up to a month until the patient experiences symptoms.

Several different types of AEMs are available:

Noncontinuous devices with memory

These devices are carried by the patient and applied to the precordial area via non-gel electrodes when the symptoms are occurring or, alternatively, a recording device may be worn on the wrist and then activated when symptoms are present. The limitation of these devices is that an arrhythmia of very short duration would be difficult to record. In addition, noncontinuous devices require reasonable dexterity on the part of the patient to apply the device correctly during a symptomatic period. This is a particular limitation if the patient is incapacitated during symptomatic periods.

Continuous "memory loop" devices

These sophisticated devices are able to continuously store a single channel of EKG data in a refreshed memory. If the patient activates the device, the EKG is then recorded form the memory loop for the preceding 30 to 90 seconds, and for the next minute or so. Therefore, these types of devices permit recording of the onset of arrhythmias or other transient events. These devices are worn continuously.

Implantable continuous "memory loop" devices

For patients with very infrequent cardiac events requiring long term monitoring, an implantable loop recorder device is inserted just under the patient's skin in the chest area during an outpatient surgical procedure. When symptoms are felt, the patient places a hand-held activator over the recorder to activate the storage of cardiac rhythms. This device can be used for more than one year. The Reveal®  Insertable Loop Recorder is an implantable memory loop device recently approved by the U.S. Food and Drug Administration (FDA).

Auto-triggered Devices

More recently, auto-triggering technology has become available which can be adapted to memory loop devices. For example, event monitors can be programmed to detect heart rates greater than 165 beats per minute, less than 40 beats per minute, or an asystole of greater than three seconds.

Real-time Outpatient Cardiac Telemetry

Real-time outpatient cardiac telemetry, also known as real-time remote heart monitors, are devices that integrate standard AEM devices with automated calling features using computer activated dialing of telephone land lines or cellular communication technology and monitoring services. As with standard AEM's, real-time remote heart monitors use similar types of EKG leads and recording devices. However, when a real-time remote heart monitor detects an arrhythmia, either automatically or by the patient himself, the EKG recorder is transmitted to a service center, which may notify the treating physician if certain criteria are met.

There are several real-time remote heart monitors available on the market in the U.S.  The CardioNet Mobile Cardiac Outpatient Telemetry Service™ (MCOT™) uses the CardioNet monitoring device, Telemetry @ Home uses the HEARTLink II™ monitoring device, Lifewatch® utilizes the Lifestar ACT (Ambulatory Cardiac Telemetry) device, Applied Cardiac Systems, Inc (ACS) uses the Core device, Biowatch™ uses the Vital Signs Transmitter (VST™), and Corventis™ utilizes the Avivo® device

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Prior Approval: 

Not applicable

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Policy: 

The use of patient activated or auto-activated external ambulatory event monitors may be considered medically necessary as a diagnostic alternative to Holter monitoring in patients who experience symptoms that are suggestive of cardiac arrhythmias less frequently than every 48 hours.

Patient activated or auto-activated external ambulatory event monitors may also be considered medically necessary for monitoring the effectiveness of medications and determining the need for treatment changes in patients whose symptoms are not well controlled.

The use of implantable ambulatory event monitors, either patient activated or auto-activated, may be considered medically necessary only in the small subset of patients who experience recurrent symptoms so infrequently that a prior trial of Holter monitor and other external ambulatory event monitors has been unsuccessful.

Other uses of ambulatory event monitors are considered investigational, including but not limited to, detection of myocardial ischemia by identifying ST segment changes.

Real-time Outpatient Cardiac Telemetry 

Real-time outpatient cardiac telemetry devices may be considered medically necessary for a narrow subset of patients when ALL of the following are met:

• Recurrent, unexplained episodes of presyncope or syncope occurring less frequently than once every 24 hours
• A non-life-threatening cardiac arrhythmia is suspected as the cause of the above symptoms
• Non-diagnostic 24-hour Holter monitor within 45 days prior to consideration of real-time outpatient cardiac telemetry.
• Patient has never demonstrated evidence of sustained ventricular tachycardia or ventricular fibrillation

Real-time outpatient cardiac telemetry devices are not intended for monitoring patients with life-threatening arrhythmias.

Use of real-time outpatient cardiac telemetry devices is considered not medically necessary outside the criteria listed above.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• 93268 Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30-day period of time; includes transmission, physician review, and interpretation
• 93270 Recording (includes hook-up, recording and disconnection)
• 93271 Monitoring, receipt of transmissions, and analysis
• 93272 Physician review and interpretation only
• 93014 Physician review with interpretation and report only
• 33282 Implantation of patient-activated cardiac event recorder
• 33284 Removal of an implantable, patient-activated cardiac even recorder
• 93298 Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, physician analysis, review(s) and report(s)
• 93285 Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with physician analysis, review and report; implantable loop recorder system
• 93291 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis
• 93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report
• 93229 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports    
• E0616 Implantable cardiac event recorder with memory, activator and programmer
• S0345 Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real time notification of monitoring station, 24-hour attended monitoring, including recording, monitoring, receipt of transmissions, analysis, and physician review and interpretation; per 24-hour period 
• S0346 Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real time notification of monitoring station, 24-hour attended monitoring, including recording, monitoring, receipt of transmissions, and analysis; per 24-hour period 
• S0347 Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real time notification of monitoring station, 24-hour attended monitoring, including physician review and interpretation; per 24-hour period  

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Selected References: 

• Ermis, C Zhu AX, Pham S et al. Comparison of automatic and patient-activated arrhythmia recordings by implantable loop recorders in the evaluation of syncope. Am J Cardiol 2003; 92(7):815-9.
• Reiffel JA, Schwarzberg R, Murry M. Comparison of autotriggered memory loop recorders versus standard loop recorders versus 24-hour Holter monitors for arrhythmia detection. Am J Cardiol 2005; 95(9):1055-9.
• Balmelli N, Naegeli B, Bertel O. Diagnostic yield of automatic and patient-triggered ambulatory cardiac event recording in the evaluation of patients with palpitations, dizziness of syncope. Clin Cardiol 2003; 26(4):173-6.
• Ng E, Stafford PJ, Ng GA. Arrhythmia detection by patient and auto-activation in implantable loop recorders. J Interv Card Electrophysiol 2004; 10(2):147-52.
• Joshi AK, Kowey PR, Prystowsky EN et al. First experience with a Mobile Cardiac Outpatient Telemetry (MCOT) system for the diagnosis and management of cardiac arrhythmia. Am J Cardiol 2005; 95(7):878-91.
• ECRI. Transtelephonic ECG Monitors for Detecting Arrhythmia. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2004, Jan 5. 14 p (ECRI Hotline Response). Also available: http://www.ecri.org. 
• ECRI. Mobile Outpatient ECG Monitoring for Detecting Arrhythmia. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005, March 15. 6 p (ECRI Hotline Responses). Also available: http//www.ecri.org.
• Agency for Healthcare Research and Quality (AHRQ). AHRP Technology Assessment Program. Remote cardiac monitoring. February 2008. Available at www.ahrq.gov.
• Rothman SA, Laughlin JC, Seltzer J et al. The Diagnosis of Cardiac Arrhythmias: A Prospective Multi-Center Randomized Study Comparing Mobile Cardiac Outpatient Telemetry Versus Standard Loop Event Monitoring. J Cardiovasc Electrophysiol. March 2007; 18: 241-47.
• Olson JA, Fouts AM, Padanilam BJ et al. Utility of Mobile Cardiac Outpatient Telemetry for the Diagnosis of Palpitations, Presyncope, Syncope, and the Assessment of Therapy Efficacy. J Cardiovasc Electrophysiol
• Saarel EV, Doratotaj S, Sterba R. Initial experience with novel mobile cardiac outpatient telemetry for children and adolescents with suspected arrhythmia. Congenit Heart Dis 2008; 3(1):33-8.
• Tayal AH, Tian M, Kelly KM et al. Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology 2008; 71(21):1696-701.
• ECRI. Mobile Cardiac Outpatient Telemetry for Detecting Arrhythmias. Plymouth Meeting (PA):ECRI Health Technology Information Service; 2010, June 16. (ECRI Hotline Service). Also available: http://www.ecri.org. 

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Policy History: 

Date                                         Reason                              Action

October 2011                          Annual review                   Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.