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Holter Monitoring (Ambulatory Electrocardiography)

Policy Number: MP-461

DRAFT

Latest Review Date: November 2019

Category: Medical                                                                 

Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.

 

Policy:

Effective for dates of service on and after December 1, 2019:

Holter Monitoring may be considered medically necessary for any of the following conditions:

 

  1. To detect a transient cardiac arrhythmia that is suspected as the cause of recurrent signs and symptoms, including recurrent near syncope, syncope, palpitations, chest pain, shortness of breath, and dizziness.
  2. To correlate chest pain discomfort and dyspnea with waveform abnormalities that are indicative of coronary insufficiency with myocardial ischemia.
  3. To assess the risk of a ventricular arrhythmia during recovery from an acute myocardial infarction or acute coronary insufficiency with myocardial ischemia, or with heart failure.
  4. To evaluate the effectiveness of anti-arrhythmic drug therapy.
  5. To determine whether an arrhythmia recurs after an anti-arrhythmic drug therapy is discontinued.
  6. To evaluate for possible pacemaker malfunction which has not been detected on a standard electronic analysis of the pacemaker, but is suspected based on patient symptoms.
  7. To assess patients with known coronary artery disease who are at high risk of dying suddenly in the period following an acute MI.
  8. To assess patients with known coronary artery disease who are high risk patients and advance to a substantially higher level of activity which may trigger increased or new types of arrhythmias necessitating treatment.  These patients have documentation that acute phase arrhythmias have not totally disappeared during the period of convalescence.
  9. Patients with a diagnosis of cryptogenic stroke who have a negative or inconclusive electrocardiogram

 

In addition, all the following criteria must be met:

  1. There must be documentation in the medical record of a detailed medical history, a thorough physical exam, selected diagnostic studies and a review of this information by the physician who ordered this procedure;
  2. The interpretation of the Holter monitoring data must be performed by a physician;
  3. There may or may not be documentation of a standard EKG being performed when a standard EKG is unlikely to capture a suspected transient rhythm disturbance or waveform abnormality.

 

More than two Holter monitors per year are considered not medically necessary.

 

Holter monitoring is considered not medically necessary for the following:

  • For the routine assessment of pacemaker function

 

 

Effective for dates of service prior to December 1, 2019:

Holter Monitoring may be considered medically necessary for any of the following conditions:

 

  1. To detect a transient cardiac arrhythmia that is suspected as the cause of recurrent signs and symptoms, including recurrent near syncope, syncope, palpitations, chest pain, shortness of breath, and dizziness.
  2. To correlate chest pain discomfort and dyspnea with waveform abnormalities that are indicative of coronary insufficiency with myocardial ischemia.
  3. To assess the risk of a ventricular arrhythmia during recovery from an acute myocardial infarction or acute coronary insufficiency with myocardial ischemia, or with heart failure.
  4. To evaluate the effectiveness of anti-arrhythmic drug therapy.
  5. To determine whether an arrhythmia recurs after an anti-arrhythmic drug therapy is discontinued.
  6. To evaluate for possible pacemaker malfunction which has not been detected on a standard electronic analysis of the pacemaker, but is suspected based on patient symptoms.
  7. To assess patients with known coronary artery disease who are at high risk of dying suddenly in the period following an acute MI.
  8. To assess patients with known coronary artery disease who are high risk patients and advance to a substantially higher level of activity which may trigger increased or new types of arrhythmias necessitating treatment.  These patients have documentation that acute phase arrhythmias have not totally disappeared during the period of convalescence.

 

In addition, all the following criteria must be met:

  1. There must be documentation in the medical record of a detailed medical history, a thorough physical exam, selected diagnostic studies and a review of this information by the physician who ordered this procedure;
  2. The interpretation of the Holter monitoring data must be performed by a physician;
  3. There may or may not be documentation of a standard EKG being performed when a standard EKG is unlikely to capture a suspected transient rhythm disturbance or waveform abnormality.

 

More than two Holter monitors per year are considered not medically necessary.

 

Holter monitoring is considered not medically necessary for the following:

  • For the routine assessment of pacemaker function

 

See Policy #356 Ambulatory Event Monitors

See Policy #460 Mobile Cardiac Outpatient Telemetry and Hybrid Devices

 

 

Description of Procedure or Service:

Ambulatory Holter electrocardiography (EKG) is a widely used noninvasive test in which an EKG is continuously recorded over an extended period of time, typically 24 to 48 hours, to evaluate symptoms suggestive of cardiac arrhythmias, i.e. palpitations, dizziness, or syncope.  This long-term ambulatory EKG recording provides a continuous record of heart rhythm during daily activities.  This procedure can often identify the existence of and determine the frequency of clinically significant rhythm disturbances and waveform abnormalities that are missed on a standard EKG.

 

Long-term EKG monitoring systems have two basic components.  One component, the recording device, provides for the recording of EKG information on magnetic tape or digital recording media to detect any significant changes in rate and rhythm as they occur.  The other component, the analysis device, provides for either graphically recording the EKG data or for visual or computer-assisted analysis of the information recorded on magnetic tape or digital recording media.

 

 

Key Points:

The literature review was performed through November 7, 2019. 

 

Summary of Evidence

For individuals who receive holter monitoring for signs and/or symptoms suggestive of arrhythmias, to correlate chest pain and dyspnea indicative of myocardial ischemia, to assess the risk of ventricular arrhythmia post myocardial infarction or heart failure, to evaluate the effectiveness or discontinuation of anti-arrhythmic drug therapy, to assess those with CAD at high risk for SCD following an MI, those who have CAD and are advancing to a higher level of activity, or those who have a diagnosis of cryptogenic stroke, the evidence includes meta-analyses, prospective studies, and observational studies. Relevant outcomes are overall survival and morbid events. Holter monitoring has been established as an effective noninvasive clinical tool in the diagnosis and assessment of cardiac patients. The evidence is sufficient to determine that the technology results in an improvement on health outcomes.

 

Practice Guidelines and Position Statements

The American College of Cardiology, American Heart Association, Heart Rhythm Society

In 2018, the ACC/AHA/HRS published a guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay.  They recommended the following:

“In the evaluation of patients with documented or suspected bradycardia or conduction disorders, cardiac rhythm monitoring is useful to establish correlation between heart rate or conduction abnormalities with symptoms, with the specific type of cardiac monitor chosen based on the frequency and nature of symptoms, as well as patient preferences. (COR I, LOE B-NR)”

 

In 2017, the AHA/ACC/HRS published a guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.  They recommended the following:

“Ambulatory electrocardiographic monitoring is useful to evaluate whether symptoms, including palpitations, presyncope, or syncope are caused by VA. (COR I, LOE B-NR)”

 

The American College of Cardiology and the American Heart Association Task Force on Practice Guidelines published a report on guidelines for ambulatory electrocardiography (AECG).  Current AECG equipment provides for the detection and analysis of arrhythmias and ST-segment deviation as well as more sophisticated analyses of R-R intervals, QRS-T morphology including late potentials, QT dispersion, and T-wave alternans.  There are two categories of AECG recorders: 1) continuous recorders, typically used for 24 to 48 hours to investigate symptoms and ECG events that are likely to occur within that timeframe, and 2) intermittent recorders, which may be used for long periods of time (weeks to months) to provide briefer, intermittent recordings for investigating events that occur infrequently.

 

The report listed the Class I, Class IIb, and Class III indications for AECG based on specific symptoms.  Class I refers to conditions for which there is evidence and / or general agreement that a given procedure or treatment is useful and effective.  The report discussed the following Class I indications for AECG:

 

  1. To assess symptoms possibly related to rhythm disturbances:
    1. Patients with unexplained syncope, near syncope, or episodic dizziness in whom the cause is not obvious,
    2. Patients with unexplained recurrent palpitations.
  2. To assess antiarrhythmic therapy:
    1. To assess antiarrhythmic drug response in individuals in whom baseline frequency of arrhythmia has been characterized as reproducible and of sufficient frequency to permit analysis.
  3. To assess pacemaker and ICD function:
    1. Evaluation of frequent symptoms of palpitation, syncope, or near syncope to assess device function to exclude myopotential inhibition and pacemaker-mediated tachycardia and to assist in the programming of enhanced features such as rate responsivity and automatic mode switching,
    2. Evaluation of suspected component failure or malfunction when device interrogation is not definitive in establishing a diagnosis,
    3. To assess the response to adjunctive pharmacological therapy in patients receiving frequent ICD therapy.

 

 

Key Words:

Holter Monitor, ambulatory electrocardiography, long-term electrocardiographic (ECG or EKG) monitoring

 

 

Approved by Governing Bodies:

There are multiple cardiovascular monitoring devices (Holter monitors) that have received U.S. Food & Drug Administration 510(k) clearances as Class II devices.

 

 

Benefit Application:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply.  Refer to member’s benefit plan.

 

 

Current Coding: 

Any existing or future devices for this service should be billed in accordance with the CPT-4 manual, the CPT Changes: An Insider’s View book, and the CPT Assistant intent and instructions. If the service is not consistent with these sources, the service should be billed with the not otherwise classified (NOC) code.

 

CPT Codes:

93224

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

93225

; recording (includes connection, recording, and disconnection).

93226

; scanning analysis with report.

93227

; review and interpretation by a physician or other qualified health care professional.

 

 

For less than 12 hours of continuous recording, use modifier 52.

 

 

References:

  1. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. . J Am Coll Cardiol. 2018 Oct 2;72(14):e91-e220.
  2. Crawford MH, Bernstein SJ, et al.  ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the guidelines for ambulatory electrocardiography).  Circulation 1999; 100:886-893.
  3. Davtyan K, Shatakhtsyan V, Poghosyan H, et al. Radiofrequency versus cryoballoon ablation of atrial fibrillation: An evaluation using ECG, Holter Monitoring, and Implantable Loop Recorders to Monitor Absolute and clinical effectiveness. Biomed Res Int. 2018 Mar 12; 2018:3629384.
  4. Gibson CM, et al.  Diagnostic and prognostic value of ambulatory ECG(Holter) monitoring in patients with coronary heart disease: a review.  Journal of Thrombosis and Thrombolysis 2007; 23(2):135-145.
  5. Gibson CM, et al.  Timing and duration of myocardial ischemia on Holter monitoring following percutaneous coronary intervention and their association with clinical outcomes (a PROTECT-TIMI 30 substudy analysis).  American Journal of Cardiology 2009; 104(1):36-40.
  6. Kadish AH, Buxton AE, et al.  ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on clinical competence (ACC/AHA Committee to develop a clinical competence statement on electrocardiography and ambulatory electrocardiography).  Journal of American College of Cardiology 2001; 38:2091-2100.
  7. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. J Am Coll Cardiol. 2019 Aug 20;74(7):e51-e156.
  8. Podrid PJ, et al.  Ambulatory monitoring in the assessment of cardiac arrhythmias.  Up to Date.  www.uptodate.com.

 

 

Policy History:

Medical Policy Group, January 2011 (2)

Medical Review Committee, March 2011

Medical Policy Administration Committee, March 2011

Medical Policy Group, September 2012: Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, December 2012 (3): 2013 Coding Updates: Verbiage update to Codes 93224 and 93227.

Medical Policy Group, January 2015 (3):  Review by consensus in conjunction with review of policies 356 & 460; no additional literature to include on this policy; no change in policy statement on this policy

Medical Policy Group, November 2019 (4): Updates to Policy statements, Key Points and References.  Added diagnosis of cryptogenic stroke with negative/inconclusive ekg is medically necessary.

Available for Comment: December 2, 2019 through January 16, 2020.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.