E0616, Implantable cardiac event recorder with memory, activator and programmer
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- The use of mobile cardiac telemetry is consideredmedically necessaryfor individuals who meet criterion A and criterion B below:
- The individual has one of the following conditions:Individuals who have symptoms suggestive of cardiac arrhythmias less frequently than once every 48 hours;orFor the detection of suspected paroxysmal atrial fibrillation following cryptogenic stroke when the monitoring is intended to guide medical management with anticoagulants;and
- Individuals who have symptoms suggestive of cardiac arrhythmias less frequently than once every 48 hours;or
- For the detection of suspected paroxysmal atrial fibrillation following cryptogenic stroke when the monitoring is intended to guide medical management with anticoagulants;and
- Previous non-diagnostic trial of external ambulatory cardiac event monitoring consisting of 14 continuous days or more.
- The use of implantable ambulatory event monitors is consideredmedically necessaryfor:
12 Active Policies
ANTHEM-CG-MED-74, CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
ANTHEM-CG-MED-40, CG-MED-40 External Ambulatory Cardiac Monitors
UHC-POL-implantable-recorders-wearable-monitors, Implantable Loop Recorders and Wearable Heart Rhythm Monitors
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
AMBETTER-CP.MP.243
Related Codes
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