DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for  Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring).

Definitions

Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Local Coverage Article (LCA) information, as well as other CMS sources, using the links below.

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.

Place of Service

Please refer to the NCD, LCD, LCA, or CMS guidelines for the place of service for electrocardiographic (EKG or ECG) monitoring (Holter or Real-Time Monitoring).

Coverage Determination and Links

HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD or state-specific LCD/LCA.

CMS Link

·       CMS Website

NCD/LCD Links

·       There are no current NCDs related to this topic.

·       LCD: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (L34636)

Article Links

LCA: Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)

Reimbursement

Participating facilities will be reimbursed per their HHO Duals contract.