Appeal type: unknown
Decision: unknown

 
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 that the following are covered indications: 
1. To detect, characterize and document symptomatic transient arrhythmias. 
2. To aid in regulating anti-arrhythmic drug dosage. 
3. To aid in the search for the cause of unexplained syncope, dizziness or giddiness. 
Based on the above covered indications, the following clinical scenarios would be considered consistent with 
the above indications: 
1. To detect the presence of symptomatic transient arrhythmias (the frequency of the symptom would 
make a 24-hour ambulatory electrocardiogram [Holter], or even lengthier, but still intermediate [e.g., up 
to 14-day monitoring], not useful in documenting the rhythm). 
2. To monitor for the purpose of regulating anti-arrhythmic drug dosages. 
3. To monitor patients who have had surgical or ablative procedures for arrhythmias. 
The following are considered not reasonable and necessary and therefore will be denied: 
1. A Cardiac Event Detection service is medically unnecessary if it offers little or no potential for new 
clinical data beyond that which has been obtained from a previous test or if other tests are better suited 
to obtain the clinical data relevant to the patients condition. The Cardiac Event Detection should be 
coordinated with results from standard EKGs, Holter monitor, along with more intermediate (e.g., up to 
14-day) monitoring tests and stress tests. 
2. For 24-hour attended monitoring services, the receiving station must be staffed on a 24-hour basis and 
should be able to direct the patient for the management of all emergencies. An answering 
service/answering machine would not fulfill this requirement. 
3. In addition, systems utilizing computers to dial the physicians office so the physician receives 
transmission by way of a relay is not a covered service since there is no attendance. 
4. Cardiac event monitoring must be 24 hours a day, seven days a week attended for reimbursement. 5. Although the service is a 30-day service, it is recognized that the event recorder may be discontinued 
once the symptom-producing arrhythmia has been documented and diagnosed or following multiple 
transmissions during symptoms, without arrhythmia. It is unlikely that the arrhythmias would always be 
diagnosed on the first day of recording or that the service would always last only one day. The average 
duration of monitoring is anticipated to last 1014 days or more. 
6. The Cardiac Event Detection service is justified by the pre-test incidence of symptoms related to 
arrhythmias and is considered not medically necessary for those patients who are not having significant 
recurrent arrhythmias that are anticipated to require treatment. 
7. Testing for more than 30 consecutive days is rarely medically necessary and the need for the continued 
monitoring must be justified by the treating physician. Failure to document an arrhythmia during a 30-
day test period is not sufficient justification to reimburse a second or subsequent test. It is unlikely to be 
medically necessary to repeat a second test within a year in the absence of new or recurrent 
undiagnosed symptoms. 
8. Event recorders must be patient-activated and may not use time-sampling technology. Accordingly, this 
test will be considered medically unnecessary for any patient who is unresponsive, comatose, severely 
confused or otherwise unable to recognize symptoms or activate the recorder. 
9. Refer to the National Coverage Determination NCD 20.15 - Electrocardiographic Services for 
monitoring after post-infarct guidelines. 
10. Because the Cardiac Event Detection service requires the diagnosis and evaluation of intermittent 
arrhythmias and patients must be continuously attached to pre-symptom loop recorders or be able to be 
attached at the start of symptoms to post-symptom loop recorders, each patient is required to have a 
recorder for his/her own exclusive use throughout the duration of the monitoring period. Recorders may 
not be shared amongst two or more patients, regardless of the environment or site of the service. It 
will be deemed medically unnecessary to perform cardiac event recording services when patients do not 
have exclusive use of a recorder for the entire service period (30 days).  
11. Cardiac Event Detection is a 30-day packaged service. Tests may not be billed within 30 days of each 
other, even if the earlier of the tests was discontinued when arrhythmias were documented and the 
patient is now reconnected for follow-up of therapy or intervention. 
You can find these rules in the Local Coverage Determination (LCD) for Cardiac Event Detection Monitoring, 
L34953 
 
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.