![]() ![]() Note: Depending on clinical presentation, the individual may have had a negative or non-diagnostic electrophysiological study (EPS) however, EPS is no longer considered a prerequisite to insertion of an implantable loop recorder. For persons without heart failure, prior myocardial infarction or significant ECG abnormalities (see appendix), symptoms occur so infrequently and unpredictably (less frequently than once per month) that noninvasive ambulatory monitoring (MCT or external loop recorders) are unlikely to capture a diagnostic ECG orįor evaluation of recurrent unexplained episodes of pre-syncope, syncope, "seizures", palpitations, or dizziness when both of the following criteria are met:įor evaluation of members with suspected atrial fibrillation as a cause of cryoptogenic stroke who have had a nondiagnostic Holter monitor or 48 hour telemetry.Īetna considers implantable loop recorders experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.For persons with heart failure, prior myocardial infarction or significant electrocardiogram (ECG) abnormalities (see appendix), noninvasive ambulatory monitoring, consisting of 30-day presymptom external loop recordings or MCT, fails to establish a definitive diagnosis or.Either of the following criteria is met:.Implantable loop recorder (e.g., Reveal Insertable Loop Recorder by Medtronic, Inc.) for the following indications: Members have a non-diagnostic Holter monitor or 48 hour telemetry, or symptoms occur infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by Holter monitoring orįor evaluation of members with suspected atrial fibrillation as a cause of cryoptogenic stroke who have had a nondiagnostic Holter monitor or 48 hour telemetry.Īetna considers MCT experimental and investigational for other indications because its effectiveness for indications other than the ones listed above has not been established.A cardiac arrhythmia is suspected as the cause of the symptoms and.Mobile cardiovascular telemetry (MCT) (e.g., CardioNet Mobile Cardiac Outpatient Telemetry Service Cardiac Telecom and Health Monitoring Services of America’s Telemetry Home Service Heartbreak ECAT, HEARTLink™ II ECG Arrhythmia Detector and Alarm System by Cardiac Telecom Corporation, LifeStar ACT by LifeWatch®, Inc., a subsidiary of Card Guard Scientific, SAVI®, Telemetry™, Trove® and Zio AT ) when either criteria in 1 or 2 is met:Įvaluation of recurrent unexplained episodes of presyncope, syncope, palpitations or dizziness when both of the following (a and b) are met: ![]() To evaluate syncope and lightheadedness in persons with a non-diagnostic Holter monitor or 48 hour telemetry, or in persons whose symptoms occur infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by Holter monitoring.Īetna considers external loop recorders experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.To document the results after an ablation procedure for arrhythmia or.To document the recurrence of an arrhythmia after discontinuation of drug therapy or.To document the benefit after initiating drug therapy for an arrhythmia or.To document ST segment depression for suspected ischemia or.To document a suspected arrhythmia in persons with a non-diagnostic Holter monitor or 48 hour telemetry (e.g., suspected atrial fibrillation as cause of cryptogenic stroke), or in persons whose symptoms occur infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by Holter monitoring (see CPB 0019 - Holter Monitors) or.External Intermittent Cardiac Event MonitorsĮxternal intermittent cardiac event monitors (i.e., external loop recorders) and external intermittent cardiac event monitors with real-time data transmission and analysis (e.g., eCardio eVolution) for any of the following conditions:.This Clinical Policy Bulletin addresses cardiac event monitors.Īetna considers the following cardiac event monitors medically necessary when applicable criteria are met: Number: 0073 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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