Mountain State Medical Policy Bulletin
Section: Diagnostic Medical
Number: M-50
Topic: Implantable Cardiac Loop Recorder
Effective Date: October 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

This monitoring service is indicated for the following:

  • 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)

When medically necessary, the implantation and removal of this device is eligible for payment and should be reported under codes 33282 and 33284. When reported for indications other than above, the procedure is considered investigational/experimental and, therefore, noncovered. Scientific evidence does not demonstrate the efficacy of this procedure for any other indications. Furthermore, this monitoring service for other indications is still being performed in a clinical trial setting with no long-term outcomes available.

In addition, the electronic analysis of the implantable loop recorder system should be reported under code 93727. This diagnostic service includes the retrieval of recorded and stored ECG/EKG data, the interpretation of the data, and reprogramming of the recorder. Payment for this electronic analysis should be allowed only once in a thirty-day period regardless of the number of events of recordings which have occurred. Charges for electronic analysis billed more frequently within the thirty-day period 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.

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

332823328493727   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Ambulatory Event Monitors, Consortium Health Plans, Inc., Policy 2.02.08, 7/98

View Previous Versions

[Version 002 of M-50]
[Version 001 of M-50]

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.