Compliance with the provisions in this policy may be monitored and addressed
through post payment data analysis and subsequent medical review audits.

  
**History/Background and/or General Information**

Ambulatory Electrocardiograph (AECG) diagnostic procedures provide a record of
the heart rhythm during daily activities. AECG can often identify the
existence and determine the frequency of clinically significant rhythm
disturbances and waveform abnormalities that are missed on a standard
electrocardiogram (ECG).

AECG continues to advance at a rapid pace and incorporates various monitoring
devices and indications for use. These devices range from Holter monitors,
Event Recorders/Monitors, Patch recorders, External Loop Recorders, Mobile
Cardiovascular Telemetry, Mobile Cardiovascular Outpatient Telemetry,
Insertable Cardiac Monitor/Internal Loop recorders, and Subcutaneous Cardiac
Rhythm Monitors. They are differentiated by capabilities and the varying
technical components among devices, such as intermittent/continuous recording,
patient/rhythm activated recording, number of leads, time frames of use and
whether the rhythm is interpreted in real time (attended surveillance) or if
it is transferred from the device and interpreted at a later time. Regardless
of the equipment, these devices provide valuable data for diagnosis of
palpitations, syncope and other signs and symptoms suggestive of cardiac
arrhythmia.

The scope of this LCD is to define the various types of AECG monitoring
devices and the specific patient indications that support medical necessity
for this monitoring.

  
**Types of cardiovascular rhythm monitors:**

**Monitor Type**

|

**Description  
** **Capability**

|

**Duration**

|

**Reports**

|

**Indications**

|

**Limitations**  
  
---|---|---|---|---|---  
  
Non-physician prescribed; hand/wrist held - smart phone based

|

Patient purchased & commercially available.

|

Patient driven review.

|

No reports generated.

|

Not to be used for diagnostic purposes.1,2,3

|

ECG diagnosis is considered pre-diagnostic pending medical verification and
not designed to be acted upon without clinician review.4  
  






Holter Monitors

|

External, continuous recording that is patient activated with a diary or
patient annotation.5 Recording is transmitted for delayed interpretation of
the computer-generated report by a physician.1

|

Collects data for 24hrs to 72 hours.5

Typically, three to 12 leads.6

|

The report provides heart rate (max-min and average) PVC, PSV, SVT, VT, PR
interval, ST segment changes.2

|

Used for frequent symptoms5 (Daily or near daily symptoms3), for patients with
recent acute coronary syndrome and/or patients with frequent ectopy on a 12-
lead EKG.2

Assess adequate rate control in A-Fib, assess for VPB, APB, or NSVT in
patients with hypertrophic cardiomyopathy.

Assess for inappropriate ST segments, Postural orthostatic tachycardia
syndromes, or suspected chronotropic incompetence.3

|

Does not provide real-time data analysis.6

  
  








Event Recorders/Monitors

|

External, intermittent recording1 that is patient activated with symptoms.

The recording is patient transmitted1 for delayed interpretation and can have
real time interpretation by an attendant surveillance office.5

Pre-symptom is patient activated or self-sensing recorders.1

Post-symptom is handheld devices activated after symptoms occur.1





|

Collects data for 24hrs to 6wks.5

Typically, a single lead1 with or without wires.

|

The report can provide heart rate (max., min., and average)

PVC, PSV, SVT, VT, PR interval, and ST segment changes.2

|

Used for patients with weekly or monthly symptoms 2 such as syncope,
dizziness, or palpitations. Used for symptoms that occur more frequently and
that were non-diagnostic with an initial Holter monitor.2



|

If the monitor is a single lead, it may not indicate location of arrhythmia
and may not be able to continuously document cardiac rhythm.1

The patient must be able to identify correct symptoms of potential arrythmia.
6

There is a possibility of substantial electrical or motion artifact that may
cause a misclassification of rhythms.4  
  
Patch recorders 5

|

External, continuous recording that is patient or rhythm activated. Recording
is automatically transmitted for delayed interpretation.5

|

Collects data for 48 hours up to 15 days.

Typically, a single lead and wireless.5



|

The report can provide heart rate (max., min. and average) PVC, PSV, SVT, VT,
PR interval, and ST segment changes.2

|

It is used to assess and detect SVT, VT, V-Fib, A-Fib5, A-Flutter, AV Block,
Mobitz type II, 3rd degree block7 and NSVT3

It is used for daily, near daily, or weekly signs and symptoms.4

|

The monitor does not localize arrhythmia origin and may provide inconsistent
ECG signal due to body type.6

Monitor may be single channel and there is a possibility of substantial
electrical or motion artifact that may cause a misclassification of rhythms.4  
  




External Loop Recorders, Vest, Belt, Mobile Cardiovascular Telemetry (MCT)
Mobile Cardiovascular Outpatient Telemetry (MCOT)

|

External, continuous recording that is patient or rhythm activated.

The recording is transmitted for delayed interpretation or for real time
interpretation by a 24-hour attendant surveillance office.

|

Collects data for two to six weeks.5

Typically, a single lead to multiple leads, with or without wires.

|

The report provides a summary of arrhythmic events with duration and frequency
with reported symptoms.2

|

Use of the monitor is based on frequent symptoms, concerns of bradycardia, or
conduction disorders.5

Used for patients with weekly or biweekly symptoms and used to assess
arrhythmia as source of palpitations, dizziness, and pre-syncope.3

Used if A-Fib is thought to be a source of cryptogenic stroke.2

Used for detection of nocturnal arrhythmias such as those associated with
sleep apnea.2

|

If the monitor is single lead

it cannot indicate the location of an arrhythmia; the P wave may not be
visible6 and there is a possibility of substantial electrical or motion
artifact that may cause a misclassification of rhythms.4 The monitor may not
be able to continuously document cardiac rhythm.

  
  






Insertable Cardiac Monitor/Internal Loop recorders (pre-symptom recorders1)
Subcutaneous Cardiac Rhythm Monitor (SCRM)

|

Implanted, continuous recording that is patient or rhythm activated. The
recording is transmitted for delayed interpretation and/or is interpreted by a
24- hour attendant surveillance office in real time.1

|

Collects data for four weeks up to 4.5 years.5

|

The report can show heart rate histograms, heart rate variability, and patient
activity data. The report can also provide arrhythmic events with duration and
frequency, with patient reported symptoms.2

|

It is used for potential bradycardia or conduction disorders that are
infrequent, recurrent, and unexplained symptoms or tachyarrhythmias.8 This
monitor is typically used after a non-diagnosed workup.5

This monitor is used when less than monthly symptoms occur that have an
undetermined etiology3 and used when prior external monitors have not been
successful in a diagnosis.2

Can be used to assess A-Fib as a source of cryptogenic stroke or post-
ablation.3

|

The monitor is surgically implanted and removed.  
  
  
PVC - Premature ventricular contractions; PSV - Paroxysmal supraventricular
tachycardia; SVT - Supraventricular tachycardia; VT - Ventricular tachycardia;
ST segment - area between sinoatrial node and ventricular repolarization; PR -
Peripheral Resistance (interval); A-Fib - Atrial Fibrillation; VPB -
Ventricular premature beats; APB - Atrial premature beats; NSVT - Non-
sustained ventricular tachycardia; V-Fib - Ventricular Fibrillation; A-Flutter
- Atrial Flutter; AV block - atrioventricular block; EKG/ECG -
electrocardiogram.

**Definitions**

**Acute Coronary Syndrome (ACS)** - applies to patients with suspicion or
confirmation of acute myocardial ischemia or infarction. It describes a large
array of signs and symptoms that range from atypical chest discomfort,
nonspecific electrocardiographic changes, and normal cardiac biomarkers, non-
ST-elevation myocardial infarction (NSTEMI), large ST-segment elevation
myocardial infarction (STEMI), and cardiogenic shock.9

**Silent Myocardial Ischemia** - is defined as 'objective documentation of
myocardial ischemia in the absence of angina or anginal equivalents.'10

**24-hour Monitoring Station** \- is defined as a facility in operation
24-hours per day, seven days a week, with a receiving station staffed on a
24-hour per day basis and can direct the patient for the management of all
emergencies.1,11,12.

**Covered Indications**

AECG monitoring will be considered medically reasonable and necessary in the
following situations:

  1. A standard 12-lead electrocardiograph (ECG), complete cardiac history and cardiac exam has not satisfactorily explained the patient's cardiac complaints and AECG testing will provide diagnostic information that will assist in developing a treatment plan or changing a treatment plan for patients that are at risk for cardiac arrythmias.1,2,6   
**OR**

  2. To aid in the regulation of anti-arrhythmic drug dosage.1,2,6,8   
**OR**

  3. To evaluate prognosis following acute coronary syndrome.2,13   
**OR**

  4. To assess for silent myocardial ischemia in a patient with known or suspected coronary heart disease.1,2   
**OR**

  5. To assess for asymptomatic ventricular premature beats or non-sustained ventricular tachycardia in patients with hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, dilated or restrictive cardiomyopathy, congenital heart disease, or Brugada syndrome.2,6   
**OR**

  6. To evaluate for occult Atrial Fibrillation (A-Fib) as a potential cause of cardio-embolism in patients with cryptogenic stroke.2,11

**Note:** It is expected that the duration of monitoring will be consistent
with the patient's signs and symptoms.1,2,4,14,15

**Limitations**

The following are considered not medically reasonable and necessary:

  1. AECG monitoring of potentially harmful ventricular arrhythmias requiring inpatient level of care.3,14
  2. Any monitoring station that does not meet the definition of 24-hour attended monitoring station as defined in the definition section.1,11,12

Please refer to NCD 20.15 for additional indications and limitations.

**Provider Qualifications**

Services will be considered medically reasonable and necessary when all
aspects of care are within the scope of practice of the provider's
professional licensure, when performed according to the supervision
requirements per state scope of practice laws, and when all procedures are
performed by appropriately trained providers in the appropriate setting.

**Notice:** Services performed for any given diagnosis must meet the
indications and limitations stated in this policy, the general requirements
for medical necessity as stated in CMS payment policy manuals, any and all
existing CMS national coverage determinations, and all Medicare payment rules.

**Clinical Practice**

Zimetbaum et al3 provides an overview and evaluation for care with patients
that present with palpitations. There are many factors to be considered in the
etiology of palpitations. Cardiac disorders are the most common cause of
palpitations and include arrythmias, structural heart disease, conduction
system abnormalities, valvular disease, pacemaker syndrome, atrial myoma,
sympathetic stimulation and catecholamine release during exercise and high
output cardiac states. Other etiology of palpitations may include psychiatric
disorders, medication effects, substance abuse, endocrine disorders, and
metabolic disorders.

The workup for a patient who presents with palpitations typically includes an
extensive medical history along with a 12-lead ECG, physical exam and limited
laboratory testing.3(p3)

When an arrythmia is not identified on the 12-lead ECG, the patient's medical
history can be helpful to note the age of symptom onset, duration of
palpitations, heart rate and rhythm regularity, additional symptoms that are
associated with the palpitations (pre-syncope or syncope), the onset and
resolution of the palpitations, effects of positional changes and if the
patient is able to alleviate the palpitations on their own. In addition, the
cardiac exam should include the patient's family cardiac history and co-
existing medical conditions such as pregnancy, metabolic and endocrine issues,
chronic obstructive pulmonary disease, and psychiatric disorders.3(p2)

Following an extensive cardiac exam, if the etiology of the palpitations
remains unclear limited laboratory testing for anemia, hyperthyroidism, and
toxicology testing may be indicated, as well as echocardiography for patients
with possible structural heart disease.

**Holter/Patch Monitors**

Barrett et al7 conducted a prospective analysis of cardiac arrythmias using
the Holter monitor and the Zio patch between April 2012 and July 2012. The
goal was to compare arrythmia detections over the course of 14 days to the
arrythmia events detected in the first 24 hours of monitoring.

One hundred and forty-six patients between the ages of 22 and 94 participated
in the study. The average wear time of the AECG monitors ranged between one
day for the Holter monitor and eleven days for the patch monitor. Both devices
were activated simultaneously and monitored for 24 hours for the Holter
monitor and up to 14 days for the patch monitor. All arrhythmias were
evaluated by the Scripps Translational Science Institute and the McNemar's
test was implemented to compare if arrythmias were clinically significant and
what type of arrythmias were detected by each monitor.

Arrythmia detection was placed into six categories: supraventricular
tachycardia (SVT) (>4 beats, not including A-Fib or A-Flutter),
A-Fib/A-Flutter (>4 beats), pause >3 seconds, atrioventricular block (Mobitz
type II or third-degree atrioventricular block), ventricular tachycardia (VT)
(>4 beats), or polymorphic ventricular tachycardia/ventricular
fibrillation.7(p14)

The results demonstrated that the "patch monitor detected 96 arrhythmia events
compared with 61 arrhythmia events by the Holter monitor ( _P_ < .001)".7(p12)
The patch monitor and Holter monitor detected the same number of events, but
"14 clinically significant arrhythmia events were detected by the adhesive
patch monitor that went undetected by the Holter monitor".7(p12)

The secondary effect was to determine the arrythmias that were detected in the
first 24 hours. It was noted that the Holter monitor detected 61 arrythmias
compared to 52 arrythmias detected by the patch monitor ( _P_ =.013). In
review of the arrythmia types three events were considered 'clinically
significant' and were ultimately detected by the patch monitor beyond the
first 24 hours.

In conclusion, the first seven days of AECG monitoring has the greatest
detection of arrythmias. Typically monitoring greater than seven days may only
provide additional 3.9% chance of identifying a different diagnosis as noted
by the Zimetbaum (1998) article..

Paudel et al16 conducted a prospective, single center study that included 335
patients who had symptoms of recurrent chronic palpitations or a single
episode of palpitations. These patients were older than 18 years of age and
the study was conducted from January 2010 to May 2012.

Patients were provided a Cardio Blue 24 Holter monitor that recorded in
either three or five channels and allowed for recording of arrythmias, as
defined by the American College of Cardiology (ACC)/American Heart Association
(AHA), with or without corresponding documented symptoms.

The arrythmias that were identified via the Holter monitor were: less than 10%
ventricular ectopy, 36.7% bigeminy, less than 10% supraventricular episodes,
5.7% non-sustained VT and 12.5% sustained VT.

The study groups were noted to be statistically significant for patients that
were younger than 50 years of age and those who were 50 years of age or older.
The highest categories of arrythmias were related to patients that were older
than 50 years of age. This study group had a 72% rate with PVC beats and 44%
with bigeminy as compared to 38.7% having PVC's and 23.1% with bigeminy that
were younger than 50 years of age.

The author reviewed literature provided by Mayet (1995) and Stein (2010). The
conclusion of those two articles determined that Holter monitors detect
arrythmias such as ventricular bigeminy, VT SVT, AV blocks, and silent
ischemia in older patients who are more at risk of sudden cardiac death.

**Event Recorders/Intermittent Monitors**

Fredriksson et al17 studied intermittent AECG recordings versus continuous
event recording in detecting A-Fib for patients 75-76 years of age. Two-
hundred and sixty-nine patients that were included in this analysis were from
the STROKESTOP II study from Europe. This study was conducted over a two-week
period with 55 days on average for the intermittent recorders and 13 days on
average for the continuous recorders. The devices were R-test 4 and Novocaor
(for continuous recording) and a 30 second handheld device Zenicor II (for
intermittent recording). All devices had activation buttons for symptomatic
arrythmias, and patients were given a symptom diary as well.

Within the study, A-Fib was defined by the European Society of Cardiology
(ESC) as "absolute irregular rate-to-rate intervals, no discernable, distinct
p-waves, and duration of at least 30 seconds" and recordings were manually
inspected and validated on computerized algorithms.17(p360)

After the review of data, it was determined that continuous event recordings
identified three times more cases of A-Fib (6%; n=15/269) than the
intermittent AECG recordings (2%; n=5/269) ( _p_ =.002). On average,
continuous recordings identified a one to eight interquartile range (IQR) on
day four and a 4 to 14 IQR on day eight for intermittent monitoring ( _P_
=.135). These IQR's were analyzed using the Mann-Whitney U test and Chi-square
tests in relation to proportions. While comparisons between the two monitoring
methods were performed, the use of the McNemar's test resulted in _P_ < .05,
which was considered significant when testing for dichotomous variables and
paired sample t-test for continuous variables.17(p356)

Surprisingly, only six percent of the patients reported symptoms within their
diaries when having a verified A-Fib and none of the patients had reported
palpitations.

Limitations of the study include: patients that were part of a larger study
(STROKESTOP II) and were thus highly motivated and possibly healthier than
peers, use of one-lead AECGs that potentially complicate the analysis of the
p-waves and a possible bias by misclassification case, and conflicts of
interest for those study team members receiving grants from companies such as
Bayer, Pfizer, Sanofi, AstraZeneca, and Medtronic.

**External Loop Recorders/Mobile Cardiovascular Outpatient Telemetry**

Favilla et al18 provides a retrospective cohort study of 227 patients with
cryptogenic stroke (179 patients) or transient ischemic stroke (48 patients).
These patients underwent a 28-day mobile cardiac outpatient telemetry (MCOT),
post cryptogenic or transient ischemic stroke. Of the 277 patients, 14% had
A-Fib detected on MCOT, 58% of which was 30 seconds in duration. It was
determined that age and prior cortical or cerebellar infarctions were
independent predictors of A-Fib.

Rothman et al19 provided a prospective clinical trial of randomized patients
that were evaluated with the CardioNet system in 17 multicenter facilities.
Two-hundred and sixty-six patients who had palpitations, presyncope, and/or
syncope were included. The goal was to confirm or exclude the etiology of
arrythmias that caused patient symptoms.

All patients had previously undergone 24 hours of monitoring with a Holter
monitor, which failed to provide diagnostic information. These patients were
placed in two groups for 30 days of monitoring with either the MCOT or with an
external looping event monitor (ELM).

During monitoring, clinically significant arrhythmias were detected in 55
(41%) patients with the MCOT versus 19 (15%) patients with the ELM (P< 0.001).
For patients who had prior syncope or presyncope, clinically significant
arrhythmias were detected in 52% of patients with MCOT and in 16% of patients
with loop recorders (P< 0.001). In most cases, the arrhythmias detected were
A-Fib, atrial flutter, or ventricular tachycardia.

There were two subgroups noted in the study. For one subgroup of patients
presenting with "syncope or presyncope, a diagnosis was made in 89% of MCOT
subjects versus 69% of LOOP subjects ( _P_ = 0.008)".19(p243) A second
subgroup analysis was performed at the centers that used auto-triggered loop
monitoring rather than patient-activated monitoring. For this subgroup, a
definitive diagnosis was obtained for 88% of MCOT patients and only 46% ( _P_
=0.002) of the ELM patients; however, this subgroup analysis involved only 50
of the 266 patients.

**Insertable Cardiac Monitor/Subcutaneous Cardiac Rhythm Monitors**

Nadkarni20 provides an overview of subcutaneous cardiac rhythm monitors (SCRM)
with the high diagnostic yield for "cryptogenic stroke, syncope, palpitation
and AF [A-Fib] Monitoring".20(p588) It has long been noted that there is no
established guideline for the use of SCRM's and the rate of false-positive
transmissions has been the 'Achilles' heel' of AECG. The author determines
that the indications for use, techniques used in implantation, programming,
and connectivity determine the clinical benefits for patients. Within this
overview the author cites the prospective randomized control trial by ABACUS.
This trial noted that SCRMs "led to more actionable events and higher rates of
antiarrhythmic discontinuation when compared with other forms of rhythm
monitoring in a post AFib ablation population".20(p588)

The versatility of the SCRM allows for adjustments in tachycardia and
bradycardia thresholds, minimum episode durations, and the detections of
atrial tachycardia and atrial fibrillation. Along with the versatility is the
ability to transmit data in two ways: alert notifications and manual downloads
by the patient via their home or cell phone application. With that noted and
continual advancements, SCRM's have proven to be beneficial for patients.

SCRM's remain a valuable tool in the diagnosis of cardiac events.

**Professional Societies and Associations**

_American College of Cardiology (ACC)/American Heart Association (AHA) Task
Force on Clinical Practice Guidelines_

Kusumoto5 provides a consensus statement on behalf of the ACC/AHA and the task
force for clinical practices. The statement provides an overview and
recommendations regarding appropriate use of AECG monitoring, particularly in
the context of diagnosing bradyarrhythmia, and patients with bradycardia and
cardiac conduction delays can be managed with a 24-to-48-hour continuous AECG.
For patients that present with symptoms that are greater than 30 days between
symptoms, the use of a broad array of modalities, such as long-term monitors,
implantable cardiac monitors, etc., would be appropriate if the initial non-
invasive evaluation was not diagnostically conclusive. The guideline indicates
that the "Choice of device is predicated on frequency of symptoms and the
degree to which symptoms incapacitate the patient" and that regardless of the
monitoring system, it is important for the system to notify health care
providers in a timely fashion, especially in regard to identifying potentially
dangerous arrythmias.5(p399)

_American Heart Association /American College of Cardiology/ Heart Rhythm
Society Clinical Practice Guidelines_

Al-khatib8 provides clinical guidelines for the use of AECG monitoring
indicating that suspected arrythmias, the frequency of arrythmias, and the
associated symptoms dictate monitor type. For example, event or 'Looping'
monitors are more appropriate and have greater diagnostic yields for sporadic
symptoms. It further explains that when ventricular arrhythmias are identified
and potentially harmful, AECG may not be appropriate. Further information upon
the use of AECG monitoring is indicated when assessing medical therapy
response.

_International Society for Holter and Noninvasive Electrocardiology (ISHNE),
and the Heart Rhythm Society (HRS) expert consensus statement_

Steinberg6 provides a consensus statement that outlined the limitations,
clinical indications, pharmacological treatment of arrythmias, and the use of
external monitoring for pacemaker malfunctioning/placement. It is noted that
for the selection of specific AECG monitors, one must consider the diagnostic
power, the monitoring capability and the accuracy, local availability, symptom
frequency, patient compliance and the condition of the patient. Within the
article there are descriptions of advantages and limitations associated with
each AECG monitor. The clinical indications for use of the various types of
monitors can include the following: syncope, bradyarrhythmia, tachyarrhythmia,
palpitations, chest pain and coronary ischemia, ischemic heart diseases and
postinfarction, hypertrophic cardiomyopathy, arrhythmic right ventricular
dysplasia/cardiomyopathy, Wolff-Parkinson - White syndrome, inherited primary
arrhythmic diseases, Short or Long QT syndrome, Brugada syndrome,
catecholaminergic polymorphic ventricular tachycardias, early repolarization
syndromes, idiopathic ventricular fibrillation with nonischemic dilated
cardiomyopathy, dialysis and chronic kidney disease associated arrythmias. It
is noted that the use of monitoring with AECG for neurological and muscular
disease is controversial. The article further indicates an appropriate
clinical assessment may include a continuous AECG, and if unsuccessful,
additional monitoring should include an intermittent external loop recording.
If patients remain undiagnosed after prolonged noninvasive monitoring, an
internal loop recorder (ILR) may be necessary.

Coverage of items and services in the Medicare program is provided based on
what is medically reasonable and necessary. This concept is operationalized by
the application of evidentiary standards, clinical validity, and clinical
utility. Over the years, AECG monitoring has advanced and evolved to include a
spectrum of technology, from the long standing Holter monitors to the present-
day Bluetooth enabled AECG monitors that allow for increased functionality and
patient convenience. Arrythmias often remain unpredictable in onset, vary in
duration and the episodes can be incapacitating and life threatening for the
patient. The evidence thresholds for coverage are a careful balance of
benefits and harms in the consideration of net health outcomes.

The FDA provides controls and guidance in relation to AECG's through the FDA
510(k) device approval. There are over 400 approved AECG monitoring devices
aimed at improving the recognition, interpretation, and etiology of various
arrythmias. With these devices, health care professionals have many choices
for obtaining the necessary diagnostic information.

In review of these clinical trials, randomized controlled trials (RCTs), meta-
analyses, societal recommendations, and literature it is noted that there are
different standards for AECG based on patient symptoms, antiarrhythmic
regulation, post internal cardiac defibrillator insertion, cryptogenic stroke,
cardio-embolism, transient ischemic stroke, silent myocardial ischemia,
conduction disorders, and the evaluation of A-Fib/A-Flutter.

It is generally expected that through a detailed exam that is based on patient
signs and symptoms, a thorough cardiac exam, review of the patient
medical/family histories to assess for conduction system abnormalities,
valvular disease, metabolic disorders, endocrine issues, chronic obstructive
pulmonary disease, structural heart disease, toxicology, and physiological
disorders, the practitioner will be able to diagnose and treat the patient. If
further diagnostic information is needed, a 12-lead EKG is appropriate and
when combined with the patient's capability and potential compliance, will aid
the healthcare provider in determining if AECG monitoring is appropriate and
which AECG monitoring device should be used.

Societal evidence provides the support for the use of AECG when evaluating for
effective use of antiarrhythmic drugs, in the context of pre/post operative
re-programing of defibrillators, to assess for known or suspected coronary
artery disease, for evaluation and assessment of asymptomatic ventricular
premature beats, and for evaluation and assessment of non-sustained
ventricular tachycardia in patients with hypertrophic cardiomyopathy,
arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, dilated or
restrictive cardiomyopathy, congenital heart disease, or Brugada syndrome.

The progression of non-invasive diagnostics to more invasive diagnostics is
the standard of care taking into consideration benefits versus harm to
patients while determining the etiology and treatment options for patients
with arrythmias. With the advancements in monitoring capabilities the ordering
provider has multiple available alternatives to determine the type of
monitoring needed and appropriate for the individual needs of the patient.

After review of the available literature, it has been determined that limited
coverage for AECG is medically reasonable when a 12-lead EKG does not provide
an adequate diagnosis. It is expected that providers will use the most
appropriate AECG device consistent with the patients' signs and symptoms.