Ambulatory Cardiac Monitors:
Monitors activated only when triggered by the individual:
ZIO Patch:
An external monitor applied by adhesive to the chest; it records continuously and typically is worn up to 14 days. It is much less expensive than the mobile cardiac output telemetry and the implantable monitors.
Mobile Cardiac Outpatient Telemetry (MCOT):
A type of loop monitor that is auto-triggered by rhythm changes and also can be triggered by the individual. It is commonly ordered for 14 or 30 day periods.
Implantable Cardiac Monitor:
A monitor implanted under the skin that can monitor continuously and can be triggered by the individual; it may be implanted for several years.
Ambulatory Cardiac Monitors
The use of individual activated or auto activated external ambulatory event monitors or continuous ambulatory monitors that record and store information for periods greater than 48 hours may be considered medically necessary as a diagnostic alternative to Holter monitoring.
Quantity Level Limits (QLL)
Additional use greater than 30 consecutive days can be made only if documentation can establish the medical need for the frequency.
The use of individual activated or auto activated external ambulatory event monitors or continuous ambulatory monitors not meeting the criteria as indicated in this policy is considered not medically necessary.
93268 |
93270 |
93271 |
93272 |
|
|
|
Ambulatory Cardiac Monitoring (ZIO Patch) and Event Monitors
The use of long-term (greater than 48 hours) external ECG monitoring by continuous rhythm recording and storage (e.g., Zio Patch) may be considered medically necessary for EITHER one of the following:
The use of long-term (greater than 48 hours) external ECG monitoring by continuous rhythm recording and storage not meeting the criteria as indicated in this policy is considered not medically necessary.
93241 |
93242 |
93243 |
93244 |
93245 |
93246 |
93247 |
93248 |
|
|
|
|
|
|
Mobile Cardiac Outpatient Telemetry (MCOT)
MCOT is limited to a select population and may be considered medically necessary when ALL of the following are met:
Note: In all cases, the individual must meet the criteria as stated unless the individual’s condition is such that a Holter monitor and an event monitor and a Zio Patch are not adequate to make a diagnosis. An explanation must be provided as to why only the MCOT would be sufficient.
Contraindications
Use of cardiac surveillance and Holter or event monitoring for the same individual on the same day is considered not medically necessary.
The use of MCOT not meeting the criteria as indicated in this policy is considered not medical necessary.
QLL
93228 |
93229 |
|
|
|
|
|
Implantable Cardiac Loop Recorder
The implantation and removal of a cardiac loop recorder may be considered medically necessary when the following criteria are met:
Note: In all cases, the individual must meet the criteria as stated unless the individual’s condition is such that a Holter monitor and an event monitor and a Zio Patch are not adequate to make a diagnosis. An explanation must be provided as to why only the MCOT would be sufficient.
The use of an implantable cardiac loop recorder not meeting the criteria as indicated in this policy is considered not medically necessary.
QLL
A remote interrogation device evaluation may be considered medically necessary once in 30 days with interim physician analysis and review. A remote interrogation device evaluation greater than 30 days are considered part of the global allowance and are not eligible for separate reimbursement.
0650T |
33286 |
93285 |
93291 |
93297 |
93298 |
E0616 |
G2066 |
|
|
|
|
|
|
Implantable Cardiac Loop Recorder for Post Cryptogenic Stroke or TIA
An implantable cardiac loop recorder, for post cryptogenic stroke or TIA, may be considered medically necessary when ALL of the following are met:
Not Medically Necessary
Implantable cardiac loop recorders post cryptogenic stroke or TIA are considered not medically necessary if an individual has ANY of the following:
An implantable cardiac loop recorder, for post cryptogenic stroke or TIA not meeting the criteria as indicated in this policy is considered not medically necessary.
0650T |
33285 |
33286 |
E0616 |
|
|
|
Covered Diagnosis Codes for procedure codes 93268, 93270, 93271, and 93272
I25.111 |
I25.118 |
I25.119 |
I25.701 |
I25.708 |
I25.709 |
I25.711 |
I25.718 |
I25.719 |
I25.721 |
I25.728 |
I25.729 |
I25.731 |
I25.738 |
I25.739 |
I25.751 |
I25.758 |
I25.759 |
I25.761 |
I25.768 |
I25.769 |
I25.791 |
I25.798 |
I25.799 |
I46.2 |
I46.8 |
I46.9 |
I47.0 |
I47.2 |
I49.3 |
I49.01 |
I49.02 |
I50.1 |
Q24.6 |
Q25.21 |
Q25.29 |
Q25.40 |
Q25.41 |
Q25.42 |
Q25.43 |
Q25.44 |
Q25.45 |
Q25.46 |
Q25.47 |
Q25.48 |
Q25.49 |
R06.3 |
R06.83 |
R06.89 |
R07.82 |
R40.4 |
|
|
|
|
|
Covered Diagnosis Codes for procedure codes 93228, 93229, 93268, 93270, 93271, and 93272
I20.1 |
I20.8 |
I20.9 |
I44.0 |
I44.1 |
I44.2 |
I44.4 |
I44.5 |
I44.7 |
I44.30 |
I44.39 |
I44.60 |
I44.69 |
I45.0 |
I45.2 |
I45.3 |
I45.4 |
I45.5 |
I45.6 |
I45.10 |
I45.19 |
I45.89 |
I47.1 |
I47.9 |
I48.0 |
I48.11 |
I48.19 |
I48.20 |
I48.21 |
I48.3 |
I48.4 |
I48.91 |
I48.92 |
I49.1 |
I49.49 |
I49.2 |
I49.5 |
R06.00 |
R06.01 |
R06.02 |
R06.09 |
R07.2 |
R07.9 |
R07.89 |
|
|
|
|
|
Covered Diagnosis Codes for procedure codes 33285, 33286, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93297, 93298, and E0616
I45.9 |
I45.81 |
I49.8 |
I49.9 |
I49.40 |
R00.1 |
R00.2 |
R42 |
R55 |
|
|
|
|
|
Covered Diagnosis Codes for procedure codes 33285, 33286, 93285, 93291, 93297, 93298, and E0616
G45.9 |
I63.81 |
I63.89 |
I63.9 |
I63.50 |
I63.59 |
I63.313 |
I63.323 |
I63.333 |
I63.343 |
I63.413 |
I63.423 |
I63.433 |
I63.511 |
I63.512 |
I63.519 |
I63.521 |
I63.522 |
I63.529 |
I63.531 |
I63.532 |
I63.539 |
I63.541 |
I63.542 |
I63.549 |
I67.841 |
I67.848 |
Z45.09 |
Z86.73 |
Z95.818 |
|
|
|
|
|
Covered Diagnosis Codes for procedure codes 93228, and 93229
121.11 |
I20.8 |
I21.01 |
I21.02 |
I21.09 |
I21.9 |
I21.A1 |
I21.A9 |
I22.0 |
I22.1 |
I22.9 |
I24.1 |
I24.8 |
I24.9 |
I25.2 |
I25.5 |
I25.6 |
I49.2 |
R00.0 |
R00.8 |
R00.9 |
Z82.49 |
Z86.74 |
|
|
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.