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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 that real-time, outpatient cardiac telemetry is limited to patients who have demonstrated a specific need for this type of cardiac telemetry service. The ordering physician must have determined and documented that patients who require this service are at low risk for a life-threatening cardiac event. In addition, the medical record must clearly demonstrate that the results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the patient.

The following uses of real-time, outpatient cardiac telemetry are considered medically reasonable and necessary:

1. Detection, characterization and documentation of symptomatic transient or paroxysmal dysrhythmia when the frequency of the symptoms is limited and the use of a 24-hour ambulatory ECG is documented in the medical record to be unlikely to capture and record the dysrhythmia, or 
2. Other testing and/or monitoring/recording/telemetry has been unrevealing. The ordering physician must document the prior testing performed and the results. This information must be maintained in the patient's medical record and be available upon request, or 
3. Prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the discontinuation of anticoagulation therapy.

Coverage Limitations

Real-time outpatient cardiac telemetry is considered medically unnecessary if it is unlikely to provide clinical data or information beyond that which has already been obtained from a previous test or if other testing (e.g., ECG, 24 hour Holter, etc.) could be expected to provide the data/information needed for the diagnosis and/or treatment of the patient's condition/symptoms.

The receiving station must be staffed with qualified personnel who provide real-time surveillance while located at the receiving station. The qualified personnel must be able to read ECGs and rhythm recordings and be capable of directing the patient if it is determined by the qualified personnel that emergency care is required. Any transfer of ongoing surveillance services to other qualified personnel, including qualified personnel at another receiving station, must occur in a seamless manner with no gaps in patient surveillance. Surveillance must occur continuously, 24 hours a day, 7 days a week while the patient is wearing the device.

A test not ordered by a physician or qualified non-physician practitioner treating the beneficiary will be denied as non-covered.

Real-time outpatient telemetry should not be used primarily for the daily transmission of ECG rhythm strips or telemetry recordings, in the absence of identified symptoms necessitating diagnosis/treatment, as stated in this LCD.
Outpatient cardiac telemetry should only be reported for patients being evaluated with cardiac telemetry as outpatients and is considered not medically necessary if used for review and interpretation of ECG rhythm strips generated by inpatient cardiac monitors or telemetry. It should not be reported for patients in hospitals, emergency rooms, skilled nursing facilities or other specialized facilities and, if reported as such, will be denied.

Real-time cardiac telemetry is considered to be a service that lasts up to 30 days and is performed for the purpose of documenting and diagnosing paroxysmal or suspected dysrhythmias. The performance of this test is based upon the ordering physician's determination that the patient's pre-test incidence of symptoms is believed to be related to a dysrhythmia. This service is considered not medically necessary for patients who do not have, or are not suspected of having, clinically significant recurrent dysrhythmias.

Testing for more than 30 consecutive days is only rarely medically necessary and the need for the continued testing must be documented by the treating physician. The inability to document a dysrhythmia during a 30-day test period is not sufficient justification to perform a second or subsequent test. It is unlikely to be medically necessary to repeat a second test within a year of a prior test.

Real-time cardiac telemetry is not covered for outpatient monitoring of recently discharged post-infarct patients and will be denied as not medically necessary.

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" among two or more patients, regardless of the environment or site of the service. Services will be denied as not medically necessary when patients do not have exclusive use of a recorder for the entire service period (up to 30 days).

Internal controls of entities performing this test must ensure uninterrupted 24/7 surveillance. Any and all transfer of patient cardiac surveillance from qualified personnel to other qualified personnel, including those who may be located at another receiving center, must occur in a seamless manner with no gaps in the provision of the surveillance service. Surveillance by qualified personnel must be performed within facilities located within the United State and its Territories. Services ordered by and/or performed by providers that are located outside of the United States or its Territories will be denied as non-covered.

Providers may not report the hook-up of outpatient cardiac telemetry as this is included in the reimbursement of the technical portion of the service.

Real-time, outpatient cardiac telemetry is contraindicated in patients considered by their physician to be at high risk of developing sustained ventricular tachycardia or ventricular fibrillation. Such patients may be more appropriately cared for in a hospital setting.

Real-time cardiac telemetry is not indicated for all patients with known or suspected dysrhythmias. It is considered reasonable and necessary only in circumstances where traditional Holter monitoring and/or other cardiac event recording is not expected to provide adequate information or has been unsuccessful in the diagnosis and/or treatment of the patient.

This service is considered to be not reasonable and necessary for all patients with symptoms such as palpitations, dizziness, or weakness. To be considered medically necessary, the ordering physician must document that he/she has concluded that the patient's symptoms are severe enough to warrant further investigation, an underlying dysrhythmia is a likely cause of their symptoms, and that the identification of the suspected dysrhythmia can only be determined through the use of this service. This information must be clearly documented in the patient's medical record.

Real-time cardiac telemetry is not covered when used for screening.

The use of multiple forms of cardiac surveillance services (e.g., Holter monitor, other event recorder) provided to the same patient on the same day is NOT medically necessary.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD. You can find this rule at the Medicare Local Coverage Determination (LCD) L34997: Real-Time, Outpatient Cardiac Telemetry.

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.