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 say that 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. 
 
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. 
 
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 
 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. 
 
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: 
 
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. 
 
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.  
You can find these rules in the National Coverage Determination (NCD) Electrocardiographic Services 20.15. 
 
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.