|
Section: |
Diagnostic Medical |
Number: |
M-50 |
Topic: |
Implantable Cardiac Loop Recorder |
Effective Date: |
January 1, 2009 |
Issued Date: |
January 5, 2009 |
Date Last Reviewed: |
12/2008 |
General Policy Guidelines
Indications and Limitations of Coverage
The implantation and removal of a cardiac loop recorder (33282, 33284) is eligible for payment when reported for the following conditions:
- palpitations (785.1)
- dizziness (780.4)
- syncope and collapse (780.2), and
- other transient symptoms which could be due to arrhythmia (426.82, 426.9, 427.60, 427.89, 427.9)
In addition, subsequent programming and interrogation device evaluations of the implantable loop recorder system should be reported under codes 93285, 93291, 93298, and 93299. Codes 93285 and 93291 represent an "in person" service. All device functions, including the battery and programmable settings are evaluated. Often, but not always, the tachycardia and bradycardia detection criteria will be adjusted during the programming evaluation.
Codes 93298 and 93299 represent a "remote" interrogation device evaluation for up to 30 days with interim physician analysis and review. This procedure is to be reported only once in 30 days. Charges billed more frequently within the thirty-day period are considered part of the global allowance and are not eligible for separate payment. A participating, preferred, or network provider cannot bill the patient separately for additional electronic analysis services during the thirty-day period.
When reported for indications other than those listed above, these procedures are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.
Description
The implantable cardiac loop recorder is a patient-activated monitoring system that permits long-term monitoring of arrhythmias in patients with recurrent but infrequent symptoms.
The device is a programmable cardiac event recorder with a looping memory and is implanted just beneath the patient's skin in the chest area. When symptoms are experienced, 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 use of this monitoring system is considered to be medically necessary only in a small subset of patients who experience symptoms so infrequently that a prolonged period of cardiac monitoring (greater than one month) is anticipated. |
- NOTE:
- 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.
|
Procedure Codes
33282 | 33284 | 93285 | 93291 | 93298 | 93299 |
Traditional Guidelines
FEP Guidelines
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
PPO Guidelines
Managed Care POS Guidelines
Publications
References
Ambulatory Event Monitors, Consortium Health Plans, Inc., Policy 2.02.08, 5/2006
Implantable Cardiac Arrhythmia Devices - Part II: Implantable Cardioverter Defibrillator and Implantable Loop Recorders, Clinical Cardiology, Vol. 29, 2006
The Utility of Implantable Loop Recorders for Diagnosing Unexplained Syncope in 100 Consecutive Patients - Five-Year, Single Center Experience, The Journal of Invasive Cardiology, Vol. 18, No. 7, July 2006
Early Application of an Implantable Loop Recorder Allows Effective Specific Therapy in Patients with Recurrent Suspected Neurally Mediated Syncope, European Heart Journal, Vol. 27, 2006 |
View Previous Versions
Table Attachment
Text Attachment
Procedure Code Attachment
Glossary
 |
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 Mountain State Blue Cross Blue Shield 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.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
|