Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Cardiac Monitoring Devices and Cardiac Procedures MP9540

Covered Service: Yes

Prior Authorization Required: No

Additional Information: None

Medicare Policy: Prior authorization is dependent on the member’s Medicare coverage. Prior authorization is not required for Dean Care Gold and Select when this service is provided by participating providers. If a member has Medicare primary and Dean Health Plan as secondary coverage, a prior authorization is required.

BadgerCare Plus Dean Health Plan covers when BadgerCare Plus also covers Policy: the benefit.

Dean Health Plan Medical Policy: 1.0 Long-Term (greater than 48 hours) Continuous Cardiac Rhythm Monitors (e.g. Zio Patch) does not require prior authorization and is considered medically necessary when ALL of the following are met: 1.1 18 years of age or older; AND 1.2 Evaluation of syncope, near-syncope, other transient loss of consciousness or palpitations including paroxysmal atrial fibrillation; AND 1.3 Holter monitoring or telemetry monitoring during hospitalization within the last 60 days fails to establish a definite diagnosis because symptoms occur so infrequently or unpredictably and therefore, prolonged testing is necessary; AND 1.4 Not utilized in the presence of an external cardiac defibrillator, pacemaker or neurostimulator. 2.0 Implantable loop recorder (cardiac event monitor) does not require prior authorization and may be indicated for ONE or more of the following: 2.1 Atrial fibrillation, known or suspected, as indicated by ALL of the following: 2.1.1 Cryptogenic stroke; AND 2.1.2 Holter monitor or other noninvasive cardiac monitor contraindicated or results unrevealing or indeterminate; AND Cardiac Monitoring Device and Cardiac Procedures 1 of 3

Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 2.1.3 Recurrent paroxysmal atrial fibrillation suspected, and test results may impact member management. 2.2 Member has a history of structural or infiltrative heart disease (e.g., valvular aortic stenosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, congenital heart disease) and ALL of the following: 2.2.1 Holter monitor or other noninvasive cardiac monitor contraindicated, or results are unrevealing or indeterminate; AND 2.2.2 Patient at high risk for arrhythmias (e.g., family history, symptoms, anatomy of structural heart disease). 2.3 Syncope, as indicated by ALL of the following: 2.3.1 Cardiac etiology of syncope, suspected as indicated by 1 or more of the following: 2.3.1.1 ECG results abnormal (e.g. cardiac rhythm other than normal sinus, significant conduction abnormalities, Brugada ECG pattern, long QT syndrome); 2.3.1.2 Family history of sudden death; 2.3.1.3 History of chronic heart failure; 2.3.1.4 History of pulmonary hypertension; 2.3.1.5 History of structural heart disease (e.g. valvular aortic stenosis, congenital heart disease, hypertrophic cardiomyopathy) or severe coronary heart disease; 2.3.1.6 Use of medication known to cause malignant arrhythmias (e.g. antiarrhythmics, antidepressants, antihistamines) 2.3.2 Recurrent or unexplained syncope; AND 2.3.3 Previous cardiac test results negative or inconclusive as indicated by 1 or more of the following: 2.3.3.1 Ambulatory cardiovascular telemetry monitor, 2.3.3.2 Electrophysiologic study 2.3.3.3 Holter monitor 2.3.3.4 Non-implantable (external) loop recorder 2.3.3.5 Patch-type cardiac monitor or tilt table testing 2.4 Ventricular arrhythmia, known or suspected. 3.0 The following cardiac devices or procedures are considered experimental and investigational, and therefore not medically necessary:

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 3.1 Intracardiac ischemia monitoring (e.g. AngelMed Guardian System) 3.2 Transcatheter tricuspid valve implantation or reimplantation with prosthetic valve 3.3 Transcatheter implantation of coronary sinus reduction device (e.g. Neovasc Reducer) 3.4 Transcatheter debulking of intracardiac mass (e.g. AngioVac system) 3.5 Transcatheter left ventricular restoration device (e.g. ventricular remodeling, surgical anterior ventricular endocardial restoration (SAVER) or the Dor procedure)

Committee/Source Date(s) Document Created: Medical Policy Committee/Health Services Division October 17, 2018 Revised: Medical Policy Committee/Health Services Division November 21, 2018 Medical Policy Committee/Health Services Division August 21, 2019 Medical Policy Committee/Health Services Division November 20, 2019 Medical Policy Committee/Health Services Division August 19, 2020 Medical Policy Committee/Health Services Division August 18, 2021 Reviewed: Medical Policy Committee/Health Services Division November 21, 2018 Medical Policy Committee/Health Services Division August 21, 2019 Medical Policy Committee/Health Services Division November 20, 2019 Medical Policy Committee/Health Services Division August 19, 2020 Medical Policy Committee/Health Services Division August 18, 2021

Published/Effective: 09/01/2021

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