Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term wearable electrocardiographic monitoring. 
 
You asked the Plan to pre-approve long-term wearable electrocardiographic monitoring (0296T, 0298T). You 
say that the enrollee has severe debilitating palpitations and needs long-term wearable electrocardiographic 
monitoring. The Plan denied your request. The Plan says a 14 day event monitor is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve long-term wearable 
electrocardiographic monitoring (0296T, 0298T). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found based on the records 
the enrollee has intermittent debilitating less than daily palpitations that were not captured on a 24-hour Holter 
monitoring.  In this circumstance, if additional cardiac monitoring were thought to be medically necessary then 
non-real time (off-line) monitoring devices such as more extended (48-hour) Holter monitoring or off-line 
event monitoring should be sufficient for identification of both symptomatic and asymptomatic dyshrythmias 
including atrial fibrillation. Likewise, self-activated non-real time and non-continuous monitoring devices 
(event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms.  
In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) 
monitoring devices with auto-triggering capability should be sufficient. There is no documentation to indicate 
 
 
the enrollee is not able to effectively manage these standard monitoring devices and no indication that these 
have been previously obtained to evaluate the enrollee's condition.  Current expert consensus guidelines 
endorsed by several national organizations also consider enrollee activated event recorders and other off-line 
monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias including atrial 
fibrillation.  Continuous real-time monitoring by telemetry services such as ZioPatch is not medically necessary 
in this case since off-line analysis of an enrollee activated device, auto-triggered device or extended continuous 
Holter monitor should be sufficient to identify dysrhythmias without jeopardizing patient safety.  Immediate 
recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry 
services is not medically necessary in this case and has not been shown to improve health outcome compared to 
standard monitoring techniques.  Mobile outpatient cardiac telemetry (ZioPatch) in this setting is more for the 
convenience of the patient/provider than it is medically necessary, 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of long-term wearable electrocardiographic monitoring (0296T, 0298T) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve long-term wearable 
electrocardiographic monitoring.