Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (code 93229) and cardiovascular monitoring services (code 93226) provided on August 17, 2022.

You asked the Plan to pay for external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services. You say that external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services are medically necessary. The Plan denied your request. The Plan says external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services do not meet the Medicare LCD coverage criteria.

The Plan follows Medicare rules.

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 pay for external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services. Our reviewer says that external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services are not medically necessary in this case. Our physician reviewer found this is a 58-year-old with the diagnosis code reported as I25.110, for whom a mobile cardiac outpatient telemetry (MCOT) monitor was provided. There is no documentation provided to support that a significant cardiac arrhythmia was a likely cause of the enrollee's
symptoms, or that the diagnosis of a significant cardiac arrhythmia as the cause of his symptoms could only be established with an MCOT monitor with real-time telemetry. There is no supportive evidence that the ordering practitioner documented that other testing and ECG monitoring had been negative. In summary, there is insufficient documentation to support the medical necessity for an MCOT monitor in this enrollee's clinical management.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage and cardiovascular monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (code 93229) and cardiovascular monitoring services (code 93226) provided on August 17, 2022.