CPT code 36005, 36010, 36011, 33282, 33284

Ambulatory Event Monitors

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page. Applicable codes: 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 33282, 33284, E0616,0295T, 0296T, 0297T, 0298T 0497T, 0498T BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

POLICY

Continuous Recorder (Holter Monitor) (93224, 93225, 93226, 93227), External Loop Recorder (codes 93268, 93270, 93271, 93272), Implantable Loop Recorder (33282, 33284, 93285, 93291, 93297, 93298, 93299, E0616), Mobile Cardiac Outpatient Telemetry (MCOT) (93228, 93229) do not require prior authorization for all product lines.
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Long-term Continuous (>48 hours) External Cardiac Monitoring Device (0295T-0298T) does not require prior authorization for HMO, PPO, Individual Marketplace, & Elite.

Long-term Continuous (>48 hours) External Cardiac Monitoring Device (0295T-0298T) is non-covered for Advantage.

Intracardiac Ischemia Monitoring (0302T-0307T) & Other Cardiac Event Monitors (as listed below) are noncovered for all product lines. (Deleted codes 0302T-0307T effective 12/31/17)

COVERED

Continuous Recorder/ Holter Monitors

The use of 24 to 48-hour continuous external cardiac monitoring and storage [CPT codes 93224, 93225, 93226, 93227, (e.g., Holter Monitor)], are considered medically necessary when any of the following criteria are met:

1. As a diagnostic tool to evaluate symptoms suggestive of cardiac arrhythmias (e.g., frequent palpitations, unexplained dizziness, or syncope)

2. To assess pacemaker or implantable cardioverter defibrillator (ICD) function for any of the following indications:
* In patients experiencing frequent symptoms of palpitation, syncope, or near syncope
* When there is a suspected component failure or malfunction
* To assess response to drug therapy in patients with an ICD

3. To assess for myocardial ischemia in suspected variant angina or known coronary artery disease when such information will impact management

4. To assess antiarrhythmic drug therapy in individuals with a treated arrhythmia

5. For pediatric patients with ANY of the following indications:
* Hypertrophic or dilated cardiomyopathies
* Possible long QT syndromes
* Congenital heart disease accompanied by significant residual hemodynamic abnormalities when surgery is being considered
* To assess the adequacy of antiarrhythmic therapy during rapid growth
* Asymptomatic non-paced congenital complete atrioventricular (AV) block

External Loop Recorder

The external loop recorder (CPT codes 93268, 93270, 93271, and 93272) is covered when the following medical indications are met:

1. To document an arrhythmia instead of using a Holter monitor, or if a Holter monitor fails to document a suspected arrhythmia; or
2. To document ST segment depression for suspected ischemia; or
3. To document the benefit after initiating drug therapy for an arrhythmia; or
4. To document recurrence of an arrhythmia after discontinuation of drug therapy; or
5. To document the results after an ablation procedure for arrhythmia; or
6. To evaluate syncope and light-headedness

Implantable Loop Recorder

The use of implantable loop recorder (CPT codes 33282, 33284, 93285, 93291, 93297, 93298, 93299, E0616) for the evaluation of recurrent unexplained episodes of fainting are also covered services, only when ALL of the following criteria are met:

1. Cardiac arrhythmia is suspected to be the cause of fainting
2. Noninvasive ambulatory monitoring failed to establish a definitive diagnosis because the symptoms occur so infrequently and unpredictably that the length of the monitoring period may have been inadequate to capture a diagnostic electrocardiogram (ECG) rhythm disorder
3. Tilt-table testing is negative or non-diagnostic

Real-time Cardiac Monitors/Mobile Cardiac Outpatient Telemetry (MCOT) MCOT (CPT codes 93228 and 93229) is covered for 30 days as medically necessary when ALL of the following criteria are met:

1. Clinical suspicion of a significant arrhythmia

2. Symptoms of syncope, presyncope, or severe palpitations occurring less frequently than once per 24 hours are present
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3. Non-diagnostic 24-hour Holter or non-real time monitoring (eg., event monitor, pacemaker telephonic telemetry, post-symptom patient-activated recorder or auto-trigger) within 60 days prior to consideration of the use of a home-based, real-time continuous attended cardiac monitoring system Documentation Requirements

1. All documentation must be maintained in the patient’s medical record and available upon request.

2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

3. The submitted medical record should support the use of the selected ICD code(s). The submitted CPT/HCPCS code should describe the service performed.

33282 Implantation of patient-activated cardiac event recorder

Coverage Status – Medicare

In the absence of a specific local coverage determination (LCD) or national coverage determination (NCD), Medicare coverage is governed by Section 1862. [42 U.S.C. 1395y] of the Social Security Act,2  which states,

“(a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services –

(1)(A) which, … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

We encourage providers to contact their Contractor Medical Director to seek coverage clarification for the useof Reveal ICM for monitoring arrhythmias.

Coverage Status – Non-Medicare

Coverage for implanting a Reveal ICM device to monitor patients with diagnoses other than that of unexplained syncope has generally not been addressed by third-party payers. Providers should contact their payer directly to determine coverage. Prior authorization may be required.

Prior Authorization Resource

A sample letter template for Prior Authorization is available through the Medtronic Coding Hotline at 1 (866) 877-4102, option 1 or by contacting your Medtronic representative. You can reach your representative by calling 1 (800) 633-8766.

Procedure Site of Service

Hospital

CPT 33282 is payable in the inpatient and outpatient settings of a hospital facility (Place of Service codes 21 and

22). The hospital bills for the costs associated with the device and implant procedure, and the physician bills for the professional services associated with the implant procedure and its 90-day global period.

Ambulatory Surgery Center

CPT 33282 is payable in the Ambulatory Surgery Center (Place of Service code 24). The ASC facility bills for the costs associated with the device and implant procedure, and the physician bills for the professional services associated with the implant procedure and its 90-day global period.

Physician Office

If a physician determines it is clinically appropriate to implant a Reveal ICM in his or her office (Place of Service code 11), they should be aware that the current US reimbursement system does not provide for payment of the Practice Expense RVUs associated with the implant procedure in this setting. Therefore, a physician will receive payment only for his or her professional services when implanting a Reveal device in the office setting.

Dialysis Shunt Maintenance Revised Medical Policy

CPT CODES

35475, 35476, 35903, 36005, 36140,36145, 36215, 36216, 36217, 35245, 36246, 36247, 36489, 36491, 36535, 36800, 36810, 36815, 36821, 36825, 36830, 36831, 36832, 36833, 36834, 36835, 36860, 36861, 37201, 37202, 37205, 37206, 37207, 37208, 37607, 37799, 75710, 75820, 75896, 75898, 75960, 75962, 75964, 75978, 76499, and 93900

Indications and Limitation of Coverage and/or Medical Necessity

Percutaneous interventions to enhance or reestablish patency of a hemodialysis AV fistula have proven useful in extending the life of the fistula and reducing the need for open repair, reconstruction, or replacement. The longevity and quality of the life of the end stage renal disease (ESRD) patient are positively impacted. Covered services are only indicated to correct a physiologically and functionally significant deficit of shunt performance.

Percutaneous AV fistula declotting, maintenance, or reestablishment of appropriate and adequate flow may encompass the following procedures. These need not all be performed on every dysfunctional shunt. Each may, under unique circumstances, be considered reasonable and medically necessary.

Open surgical therapy for thrombosed dialysis cannula or hemodynamically significant flow impediment utilizes direct access to the conduit and contiguous vessels. Mechanical fragmentation and surgical removal of occlusive thrombotic material is effected under direct visualization. Adjunctive thrombolytic pharmacotherapy may be employed.

Residual vascular stenoses or obstructive lesions are removed and corrected using standard vascular surgical techniques; “e.g., CPT Code 36832, Revision, arteriovenous fistula; without thrombectomy, autogenous or non-autogenous dialysis graft (separate procedure). 36834, Plastic repair arteriovenous aneurysm (separate procedure).”

Italicized, and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.