Cardiac Event Detection Monitoring Cardiac event monitor technology varies among different devices. For patient-activated event monitors, the patient initiates recording when symptoms appear or when instructed to do so by a physician (e.g., following exercise). For self-sensing, automatically triggered monitors, an EKG is automatically recorded when the device detects an arrhythmia, without patient intervention. Some devices permit a patient to transmit EKG data trans-telephonically (i.e., via telephone) to a receiving center where the data is reviewed. A technician may be available at these centers to review transmitted data 24 hours per day. In some instances, when the EKG is determined to be outside certain preset criteria by a technician or other non-physician, a physician is available 24 hours per day to review the transmitted data and to make clinical decisions regarding the patient. These services are known as "24-hour attended monitoring". In other instances, transmitted EKG data is reviewed at a later time and are, therefore, considered "nonattended." Cardiac event monitors without trans-telephonic capability must be removed from the patient and taken to a location for review of the stored EKG data. Some devices also permit a "time sampling" mode of operation. The "time sampling" mode is not covered under ambulatory EKG monitoring technology. Some cardiac event monitoring devices with trans-telephonic capabilities require the patient to dial the phone number of a central EKG data reception center and initiate transmission of EKG data. Other devices use Internet-based in-home computers to capture and store EKG data. When such devices detect pre-programmed arrhythmias, data is automatically sent via modem and standard telephone lines to a central receiving center, where the data is reviewed. Internet-based in-home computer systems may also provide the receiving center with a daily computer-generated report that summarizes 24 hours of EKG data. Dynamic Electrocardiogram (Holter Monitoring) Transtelephonic EKG Indications and Limitations of Coverage Cardiac Event Detection Monitoring Pre-symptom Memory Loop Recorder (MLR)
Post-symptom Recorder The following indications are covered:
Certain uses other than those specified above may be covered if such use is determined to be medically necessary. Additionally, the transmitting devices must meet at least the following criteria:
24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described below: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies. The following indications are non-covered:
Dynamic Electrocardiogram (Holter Monitoring) Transtelephonic EKG
Certain uses other than those specified above may be covered if, in the judgment of the Plan, such use is medically necessary. Additionally, the transmitting devices must meet at least the following criteria:
24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described below: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies. The following is non-covered:
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Social Security Act, Section 1156(a)(1). This section states that the health care practitioner must assure services will be provided economically and only when, and to the extent, medically necessary. CMS Online Manual Pub. 100-3, Chapter 1, Section 20.15
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 circumstances may warrant individual consideration, based on review of applicable medical records. Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern. Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions. Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. |