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
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to the protocol titled Medical Records Documentation Used for Reviews).
- Documentation that noninvasive cardiac event recording was attempted and yielded non-diagnostic results after at least two weeks of monitoring, or documentation of contraindication to noninvasive monitoring.
- Clinical documentation supporting one or more covered indications (e.g., cryptogenic stroke or other documented systemic thromboembolic event, suspected/known ventricular arrhythmia, high-risk structural or infiltrative heart disease with examples listed in policy, recurrent or unexplained infrequent syncope with documentation of medication modification or association with autonomic dysfunction, or abnormal electrophysiology study/tilt table testing).
Key Coverage Criteria
- Implantable Loop Recorders are proven and medically necessary for evaluating suspected cardiac arrhythmias when noninvasive cardiac event recording is contraindicated or yielded non-diagnostic results after at least two weeks of monitoring in one or more of the following circumstances:
- Suspected paroxysmal atrial fibrillation in the setting of a cryptogenic stroke or another documented systemic thromboembolic event
- Suspected or known ventricular arrhythmia
- High risk for arrhythmia secondary to structural or infiltrative heart disease such as aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease, family history, dilated ischemic or nonischemic cardiomyopathy, or use of medications known to cause malignant arrhythmias such as those prolonging the QT interval
- Recurrent or unexplained infrequent syncope, after modification of potentially syncope-causing medications or associated with autonomic dysfunction
- Abnormal tests such as electrophysiology study or tilt table testing
8 Active Policies
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
AMBETTER-CP.MP.243 — Implantable Loop Recorder
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
CARELON-ambulatory-cardiac-rhythm-monitoring-2024-07-01
Related Codes
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