C1764, Event recorder, cardiac (implantable)
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- For ILR in recurrent or unexplained syncope: documentation that non-arrhythmic causes have been excluded by appropriate testing (e.g., reflex syncope, orthostatic hypotension, volume depletion, dehydration, blood loss).
- For ILR in recurrent or unexplained syncope and for cryptogenic stroke/TIA: documentation that noninvasive ambulatory cardiac monitoring for a minimum of 14 days was performed and was inconclusive or non-diagnostic (e.g., patch monitors, external event monitors).
- For replacement of an implantable electrocardiographic event monitor: documentation that the individual continues to meet ALL ILR criteria and that the existing monitor is no longer under warranty and cannot be repaired (e.g., device nearing end of battery life).
- For pediatric ILR: documentation that an external monitor has not demonstrated the symptoms of concern prior to ILR implantation.
Key Coverage Criteria
- Ambulatory external cardiac monitoring from 48 hours to 30 days (Current Procedural Terminology [CPT®] codes 93241-93248, 93268, 93270-93272, 0937T-0940T) is considered medically necessary when ANY of the following criteria are met:
- symptoms of presyncope, syncope, or severe palpitations when there is clinical suspicion of a significant bradyarrhythmia or tachyarrhythmia
- evaluation of atrial fibrillation for rhythm and/or rate control when the results will directly impact clinical decision-making (pre- and/or post-ablation)
- following stroke or transient ischemic attack (TIA) of undetermined cause (CPT® 93268, 93270-93272)
- following cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL) if individual is not receiving ongoing anticoagulation and deemed to be at high thromboembolic risk (e.g., CHA2DS2-VASc score ≥ 2)
- individual with hypertrophic cardiomyopathy
10 Active Policies
CIGNA-0547, Ambulatory External and Implantable Electrocardiographic Monitoring
ANTHEM-CG-MED-74, CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
AMBETTER-CP.MP.243, Implantable Loop Recorder
BCBSIL-MED202.003, Long-Term Ambulatory Cardiac Monitoring (Outpatient Cardiac Telemetry, Implantable Cardiac Rhythm Event Monitors, and Intracardiac Ischemia Detection Systems)
BCBSMT-MED202.003
Related Codes
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