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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state: 
 
 A. General 
1. An electrocardiogram (EKG) is a graphic representation of electrical activity within the heart. 
Electrodes placed on the body in predetermined locations sense this electrical activity, which is then 
recorded by various means for review and interpretation. EKG recordings are used to diagnose a wide 
range of heart disease and other conditions that manifest themselves by abnormal cardiac electrical 
activity. 
EKG services are covered diagnostic tests when there are documented signs and symptoms or other 
clinical indications for providing the service. Coverage includes the review and interpretation of EKGs 
only by a physician. There is no coverage for EKG services when rendered as a screening test or as part 
of a routine examination unless performed as part of the one-time, Welcome to Medicare preventive 
physical examination under section 611 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003. 
2. Ambulatory electrocardiography (AECG) refers to services rendered in an outpatient setting over a 
specified period of time, generally while a patient is engaged in daily activities, including sleep. AECG 
devices are intended to provide the physician with documented episodes of arrhythmia, which may not 
be detected using a standard 12-lead EKG. AECG is most typically used to evaluate symptoms that may 
correlate with intermittent cardiac arrhythmias and/or myocardial ischemia. Such symptoms include 
syncope, dizziness, chest pain, palpitations, or shortness of breath. Additionally, AECG is used to 
evaluate patient response to initiation, revision, or discontinuation of arrhythmic drug therapy. 
3. The Centers for Medicare & Medicaid Services (CMS), through the national coverage determination 
(NCD) process, may create new ambulatory EKG monitoring device categories if published, peer-
reviewed clinical studies demonstrate evidence of improved clinical utility, or equal utility with 
additional advantage to the patient, as indicated by improved patient management and/or improved 
health outcomes in the Medicare population (such as superior ability to detect serious or life-threatening 
arrhythmias) as compared to devices or services in the currently described categories below. 
 
Descriptions of Ambulatory EKG Monitoring Technologies 
1. Dynamic electrocardiography devices that continuously record a real-time EKG, commonly known as 
HolterTM monitors, typically record over a 24-hour period. The recording is captured either on a 
magnetic tape or other digital medium. The data is then computer-analyzed at a later time, and a 
physician interprets the computer-generated report. A 24-hour recording is generally adequate to detect most transient arrhythmias. Documentation of medical necessity is required for monitoring longer than 
24 hours. The recording device itself is not covered as durable medical equipment (DME) separate from 
the total diagnostic service. 
2. An event monitor, or event recorder, is a patient-activated or event-activated EKG device that 
intermittently records cardiac arrhythmic events as they occur. The EKG is recorded on magnetic tape 
or other digital medium. 
Cardiac event monitor technology varies among different devices. For patient-activated event monitors, 
the patient initiates recording when symptoms appear or when instructed to do so by a physician (e.g., 
following exercise). For self-sensing, automatically triggered monitors, an EKG is automatically 
recorded when the device detects an arrhythmia, without patient intervention. Some devices permit a 
patient to transmit EKG data transtelephonically (i.e., via telephone) to a receiving center where the 
data is reviewed. A technician may be available at these centers to review transmitted data 24 hours per 
day. In some instances, when the EKG is determined to be outside certain pre-set criteria by a 
technician or other non-physician, a physician is available 24 hours per day to review the transmitted 
data and to make clinical decisions regarding the patient. These services are known as 24-hour 
attended monitoring. In other instances, transmitted EKG data is reviewed at a later time and are, 
therefore, considered non-attended. 
Cardiac event monitors without transtelephonic capability must be removed from the patient and taken 
to a location for review of the stored EKG data. Some devices also permit a "time sampling" mode of 
operation. The "time sampling" mode is not covered under ambulatory EKG monitoring technology. 
Some cardiac event monitoring devices with trans-telephonic capabilities require the patient to dial the 
phone number of a central EKG data reception center and initiate transmission of EKG data. Other 
devices use Internet-based in-home computers to capture and store EKG data. When such devices detect 
pre-programmed arrhythmias, data is automatically sent via modem and standard telephone lines to a 
central receiving center, or independent diagnostic testing facility (IDTF), where the data is reviewed. 
Internet-based in-home computer systems may also provide the receiving center with a daily computer-
generated report that summarizes 24 hours of EKG data. 
Certain cardiac event monitors capture electrical activity with a single electrode attached to the skin. 
Other devices may employ multiple electrodes in order to record more complex EKG tracings. 
Additionally, devices may be individually programmed to detect patient-specific factors, electrode 
malfunction, or other factors. Cardiac event monitors can be further categorized as either pre-event or 
post-event recorders, based on their memory capabilities: 
a. Pre-symptom Memory Loop Recorder (MLR) 
Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., 
memorize) an interval of pre-symptom EKG data along with data during and subsequent to the 
symptomatic event. Self-sensing recorders (also known as event-activated or automatic trigger) 
do not require patient input to capture these data. Single or multiple events may be recorded. 
The device is worn at all times, usually for up to 30 days. 
o Implantable (or Insertable Loop) Recorder (ILR) 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left 
chest and may remain implanted for many months. An ILR is used when syncope is thought to 
be cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR. 
b. Post-symptom Recorder 
The patient temporarily places this device against the chest when symptoms occur and activates 
it by pressing a button. These recorders represent old technology, as they do not include a 
memory loop. The device transmits EKG data telephonically in real-time and is usually used for 
up to 30 days. 
 
 B. Nationally Covered Indications 
The following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided, see C.5. below). 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. 
Additionally, the transmitting devices must meet at least the following criteria: 
a. They must be capable of transmitting EKG Leads, I, II, or III; and, 
b. The tracing must be sufficiently comparable to a conventional EKG. 
24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only 
covered if provision is made for such 24-hour attended coverage in the manner described below: 
24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician 
or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. 
Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and 
make clinical decisions regarding the patient. The technician should also be instructed as to when and how to 
contact available facilities to assist the patient in case of emergencies. 
 
C. Nationally Non-Covered Indications 
The following indications are non-covered nationally unless otherwise specified below: 
1. The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/recording. 
2. Separate physician services other than those rendered by an IDTF unless rendered by the patients 
attending or consulting physician. 
3. Home EKG services without documentation of medical necessity. 
4. Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time of 
service or immediately thereafter. 
5. 24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI unless 
provision is made for such 24-hour attended coverage in the manner described in section B.5. above. 
6. Any marketed Food and Drug Administration (FDA)-approved ambulatory cardiac monitoring device 
or service that cannot be categorized according to the framework below. 
You can find this information in the Medicare National Coverage Determination (NCD)- 20.15, 
Electrocardiographic Services. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.