For evaluation of recurrent unexplained episodes of pre-syncope, syncope, "seizures", palpitations, or dizziness when both of the following criteria are met:.
For persons without heart failure, prior myocardial infarction or significant ECG abnormalities (see appendix), symptoms occur so infrequently and unpredictably (less frequently than once per month) that noninvasive ambulatory monitoring (MCT or external loop recorders) are unlikely to capture a diagnostic ECG or.
For persons with heart failure, prior myocardial infarction or significant electrocardiogram (ECG) abnormalities (see appendix), noninvasive ambulatory monitoring, consisting of 30-day presymptom external loop recordings or MCT, fails to establish a definitive diagnosis or. Either of the following criteria is met:. A cardiac arrhythmia is suspected as the cause of the symptoms and. Members have a non-diagnostic Holter monitor or 48 hour telemetry, or symptoms occur infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by Holter monitoring orįor evaluation of members with suspected atrial fibrillation as a cause of cryoptogenic stroke who have had a nondiagnostic Holter monitor or 48 hour telemetry.Īetna considers MCT experimental and investigational for other indications because its effectiveness for indications other than the ones listed above has not been established.Īetna considers an implantable loop recorder (e.g., Reveal Insertable Loop Recorder by Medtronic, Inc.) medically necessary for the following indications:. A cardiac arrhythmia is suspected as the cause of the symptoms and. To evaluate syncope and lightheadedness in persons with a non-diagnostic Holter monitor or 48 hour telemetry, or in persons whose symptoms occur infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by Holter monitoring.Īetna considers external loop recorders experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.Īetna considers mobile cardiovascular telemetry (MCT) (e.g., CardioNet Mobile Cardiac Outpatient Telemetry (MCOT) Service Cardiac Telecom and Health Monitoring Services of America’s Telemetry Home Service Heartbreak ECAT (External Cardiac Ambulatory Telemetry) (Med net Healthcare Technologies), HEARTLink™ II ECG Arrhythmia Detector and Alarm System by Cardiac Telecom Corporation, LifeStar ACT by LifeWatch®, Inc., a subsidiary of Card Guard Scientific, SAVI® (Mediacom), Telemetry™ (Scott Care Cardiovascular Solutions) and Trove® (Biomedical Systems)) medically necessary when either criteria in A or B is met:Įvaluation of recurrent unexplained episodes of presyncope, syncope, palpitations or dizziness when both of the following (1 and 2) are met:
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