Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry Printer-Friendly Version   

Medical Policy: 02.02.11 
Original Effective Date: April 2006 
Reviewed: August 2008 
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

Mobile Outpatient Cardiac Telemetry

Mobile 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.

Currently, two real-time remote heart monitors are available on the market in the U.S. The CardioNet Mobile Cardiac Outpatient Telemetry Services uses the CardioNet monitoring device, and Telemetry @ Home uses the HEARTlink II^TM monitoring device.

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.

Outpatient Cardiac Telemetry

Outpatient cardiac telemetry or real-time event monitoring is considered investigational as an alternative to auto-activated ambulatory event monitors for all applications. This is because there is not adequate evidence to show that this technology is more effective than conventional ambulatory event monitors or has greater impact on patient management.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• CPT 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
• CPT 93270 Recording (includes hook-up, recording and disconnection)
• CPT 93271 Monitoring, receipt of transmissions, and analysis
• CPT 93272 Physician review and interpretation only
• CPT 93014 Physician review with interpretation and report only
• CPT 33282 Implantation of patient-activated cardiac event recorder
• CPT 33284 Removal of an implantable, patient-activated cardiac even recorder
• CPT 93727 Electronic analysis of implantable loop recorder (ILR) system (includes retrieval of recorded and stored ECG data, physician review and interpretation of retrieved ECG data and reprogramming)
• HCPCS E0616 Implantable cardiac event recorder with memory, activator and programmer
• HCPCS 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 
• HCPCS 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 
• HCPCS 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: 

• The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
• 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.

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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