CLINICAL MEDICAL POLICY Policy Name: Electrocardiographic Services (NCD 20.15) Policy Number: MP-053-MC-ALL Responsible Department(s): Medical Management Provider Notice Date: 05/01/2018 Issue Date: 06/01/2018 Effective Date: 06/01/2018 Annual Approval Date: 03/21/2019 Revision Date: N/A Products: Pennsylvania Medicare Assured All participating and nonparticipating hospitals and Application: providers Page Number(s): 1 of 24

DISCLAIMER

Gateway Health℠ (Gateway) medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Gateway Health℠ may provide coverage under the medical-surgical benefits of the Company’s Medicare products for medically necessary electrocardiographic services.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

Policy No. MP-053-MC-ALL Page 1 of 24

Definitions

Electrocardiogram (EKG) is a graphic representation of electrical activity within the . 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.

Ambulatory Electrocardiography (AECG) is a diagnostic test 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 , 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 and/or myocardial . Types of cardiac event monitors include:  Dynamic Electrocardiogram (Holter Monitoring) are devices that continuously record a real-time EKG, commonly known as Holter™ monitors, that 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.  Cardiac Event Detection Monitoring is used to 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. o Pre-symptom Memory Loop Recorder (MLR) A recorder that 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. Charges billed more frequently within the 30-day period should be denied as not covered and not billable to the member. o Implantable (or Insertable Loop) Recorder (ILR) Another type of pre-symptom MLR. It is implanted subcutaneously in a patient's 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 Holter monitor or a traditional pre-symptom MLR. o Post-symptom Recorder The patient temporarily places this device against the chest when symptoms occur and activates it by pressing a button. These recorders represent old technology, as they do not include a memory loop. The device transmits EKG data telephonically in real-time and is usually used for up to 30 days.

Policy No. MP-053-MC-ALL Page 2 of 24 Procedures

Indications and Limitations of Coverage 1. Nationally Covered Indications The following indications are covered nationally unless otherwise indicated:  Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.  EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.  Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.  Home EKG services with documentation of medical necessity.  Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to: o Detect, characterize, and document symptomatic transient arrhythmias; o Initiate, revise, or discontinue arrhythmic drug therapy; or o Carry out early post-hospital monitoring of patients discharged after (MI) (only if 24-hour coverage is provided, see below).

Certain uses other than those specified above may be covered if, in the judgment of the local contractor, such use is medically necessary.

Additionally, the transmitting devices must meet at least the following criteria:  They must be capable of transmitting EKG Leads, I, II, or III; and  The tracing must be sufficiently comparable to a conventional EKG.

24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described here: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies.

2. Nationally Non-covered Indications The following indications are non-covered nationally unless otherwise specified below:  The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/ recording.

Policy No. MP-053-MC-ALL Page 3 of 24  Separate physician services other than those rendered by an IDTF unless rendered by the patient's attending or consulting physician.  Home EKG services without documentation of medical necessity.  Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time of service or immediately thereafter.  24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI unless provision is made for such 24-hour attended coverage in the manner described above.  Any marketed Food and Drug Administration (FDA)-approved ambulatory cardiac monitoring device or service that cannot be categorized according to the framework below.

3. Other Ambulatory cardiac monitoring performed with a marketed, FDA-approved device is eligible for coverage if it can be categorized according to the framework below. Unless there is a specific NCD for that device or service, determination as to whether a device or service that fits into the framework is reasonable and necessary is according to local contractor discretion. Charges billed more frequently within the thirty-day period should be denied as not covered and not billable to the member.

Electrographic Services Framework

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 above.

4. Post-payment Audit Statement The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Gateway Health℠ at any time pursuant to the terms of your provider agreement.

Policy No. MP-053-MC-ALL Page 4 of 24 5. Place of Service The place of service for electrocardiographic studies is outpatient.

Operational Guidelines This medical policy will be applied on a post-service, prepayment basis for both professional and facility claims.

Coverage Determination Gateway Health℠ follows the coverage determinations made by CMS as outlined in either the national coverage determinations (NCD) or the state-specific local carrier determination (LCD).

NCD: Electrocardiographic Services (20.15) https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=179&ncdver=2&DocID=20.15&from2=search.asp&bc=gAAAAAgAAAAAAA%3d%3d&

There is an LCD that supplements this policy but does not supersede or repeat the determinations mentioned above. Please use the following Novitas Solutions LCD (L34953) Cardiac Event Detection Monitoring, as reference: S:\Medical Policy Development\MEDICARE POLICIES\PA Medicare Medical Policies\2018 PA Medicare Medical Policies\MP-054-MC-PA Cardiac Event Detection\Research and Information\Local Coverage Determination for Cardiac Event Detection Monitoring (L34953)_aspx.mht

For Pennsylvania, please use the following link for Novitas Solutions List of LCDS: https://www.novitassolutions.com/webcenter/portal/MedicareJL/page/pagebyid?contentId=00024370 &_afrLoop=578664761207593#!%40%40%3F_afrLoop%3D578664761207593%26contentId%3D0002437 0%26_adf.ctrl-state%3D49ww9vpbm_55

CODING REQUIREMENTS

The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non- covered health service. Benefit coverage for health services is determined by the member-specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Coding Clarifications: Do NOT report 0295T-0298T in conjunction with 93224-93272 for the same monitoring period.

Covered Procedure Codes CPT Description Codes 0295T External electrocardiographic recording for more than 48 hours up to 21 says by continuous rhythm recording and storage, includes recording, scanning analysis with report, review and interpretation

Policy No. MP-053-MC-ALL Page 5 of 24 0296T External electrocardiographic recording for more than 48 hours up to 21 says by continuous rhythm recording and storage, includes recording, scanning analysis with report, review and interpretation; recording (includes connection and initial recording) 0297T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report 0298T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93226 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 93229 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional 93268 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, review and interpretation by a physician or other qualified health care professional 93270 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection)

Policy No. MP-053-MC-ALL Page 6 of 24 93271 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; transmission and analysis 93272 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; review and interpretation by a physician or other qualified health care professional

Covered Diagnosis Codes For Procedure Codes 0295T-0298T ICD-10 Description Codes A02.1 Salmonella sepsis A18.84 Tuberculosis of heart G45.9 Transient cerebral ischemic attack, unspecified I20.0 Unstable I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I24.0 Acute not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I25.110 Atherosclerotic heart disease of native coronary artery with pectoris I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I25.2 Old myocardial infarction I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris

Policy No. MP-053-MC-ALL Page 7 of 24 I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris I44.0 , first degree I44.1 Atrioventricular block, second degree I44.2 Atrioventricular block, complete I44.30 Unspecified atrioventricular block I44.39 Other atrioventricular block I44.4 Left anterior fascicular block I44.5 Left posterior fascicular block

Policy No. MP-053-MC-ALL Page 8 of 24 I44.69 Other fascicular block I44.7 Left bundle-branch block, unspecified I45.0 Right fascicular block I45.19 Other right bundle-branch block I45.2 I45.3 I45.4 Nonspecific I45.5 Other specified I45.6 Pre-excitation syndrome I45.81 Long QT syndrome I45.89 Other specified conduction disorders I45.9 Conduction disorder, unspecified I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular I47.2 I47.9 , unspecified I48.0 Paroxysmal atrial I48.1 Persistent I48.2 Chronic atrial fibrillation I48.3 Typical I48.4 Atypical atrial flutter I48.91 Unspecified atrial fibrillation I48.92 Unspecified atrial flutter I49.01 I49.02 I49.1 Atrial premature depolarization I49.2 Junctional premature depolarization I49.3 Ventricular premature depolarization I49.40 Unspecified premature depolarization I49.49 Other premature depolarization I49.5 Sick sinus syndrome I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified R00.0 Tachycardia, unspecified R00.1 , unspecified R00.2 Palpitations R06.01 Orthopnea R06.02 Shortness of breath R06.09 Other forms of dyspnea R06.2 Wheezing R06.3 Periodic breathing R06.4 Hyperventilation

Policy No. MP-053-MC-ALL Page 9 of 24 R06.81 Apnea, not elsewhere classified R06.82 Tachypnea, not elsewhere classified R06.83 Snoring R06.89 Other abnormalities of breathing R07.2 Precordial pain R07.82 Intercostal pain R07.89 Other R07.9 Chest pain, unspecified R29.5 Transient paralysis R40.4 Transient alteration of awareness R42 Dizziness and giddiness R55 Syncope and collapse Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy

Covered Diagnosis Codes for Codes 93228 – 93229 ICD-10 Codes Description G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.8 Other transient cerebral ischemic attacks and related syndromes G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

Policy No. MP-053-MC-ALL Page 10 of 24 I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I24.9 Acute ischemic heart disease, unspecified I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris I25.2 Old myocardial infarction I25.3 Aneurysm of heart I25.41 Coronary artery aneurysm I25.5 Ischemic I25.6 Silent myocardial ischemia I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris

Policy No. MP-053-MC-ALL Page 11 of 24 I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris I25.84 Coronary atherosclerosis due to calcified coronary lesion I25.89 Other forms of chronic ischemic heart disease I25.9 Chronic ischemic heart disease, unspecified I31.0 Chronic adhesive I31.1 Chronic constrictive pericarditis I34.0 Nonrheumatic mitral (valve) insufficiency I34.1 Nonrheumatic mitral (valve) prolapse I34.2 Nonrheumatic mitral (valve) stenosis I34.8 Other nonrheumatic disorders I34.9 Nonrheumatic mitral valve disorder, unspecified I35.0 Nonrheumatic aortic (valve) stenosis I35.1 Nonrheumatic aortic (valve) insufficiency I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency

Policy No. MP-053-MC-ALL Page 12 of 24 I35.8 Other nonrheumatic disorders I35.9 Nonrheumatic aortic valve disorder, unspecified I42.0 I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I42.3 Endomyocardial (eosinophilic) disease I42.4 Endocardial fibroelastosis I42.5 Other restrictive cardiomyopathy I42.6 I42.7 Cardiomyopathy due to drug and external agent I42.8 Other I42.9 Cardiomyopathy, unspecified I43 Cardiomyopathy in diseases classified elsewhere I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree I44.2 Atrioventricular block, complete I44.30 Unspecified atrioventricular block I44.39 Other atrioventricular block I44.4 Left anterior fascicular block I44.5 Left posterior fascicular block I44.60 Unspecified fascicular block I44.69 Other fascicular block I44.7 Left bundle-branch block, unspecified I45.0 Right fascicular block I45.10 Unspecified right bundle-branch block I45.19 Other right bundle-branch block I45.2 Bifascicular block I45.3 Trifascicular block I45.4 Nonspecific intraventricular block I45.5 Other specified heart block I45.6 Pre-excitation syndrome I45.81 Long QT syndrome I45.89 Other specified conduction disorders I45.9 Conduction disorder, unspecified I46.2 due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation

Policy No. MP-053-MC-ALL Page 13 of 24 I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.91 Unspecified atrial fibrillation I48.92 Unspecified atrial flutter I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.1 Atrial premature depolarization I49.2 Junctional premature depolarization I49.3 Ventricular premature depolarization I49.40 Unspecified premature depolarization I49.49 Other premature depolarization I49.5 Sick sinus syndrome I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 I51.9 Heart disease, unspecified I52 Other heart disorders in diseases classified elsewhere I63.40 Cerebral infarction due to embolism of unspecified cerebral artery I63.411 Cerebral infarction due to embolism of right middle cerebral artery I63.412 Cerebral infarction due to embolism of left middle cerebral artery I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery I63.421 Cerebral infarction due to embolism of right anterior cerebral artery I63.422 Cerebral infarction due to embolism of left anterior cerebral artery I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery I63.431 Cerebral infarction due to embolism of right posterior cerebral artery I63.432 Cerebral infarction due to embolism of left posterior cerebral artery

Policy No. MP-053-MC-ALL Page 14 of 24 I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery I63.441 Cerebral infarction due to embolism of right cerebellar artery I63.442 Cerebral infarction due to embolism of left cerebellar artery I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other cerebral artery I66.01 Occlusion and stenosis of right middle cerebral artery I66.02 Occlusion and stenosis of left middle cerebral artery I66.03 Occlusion and stenosis of bilateral middle cerebral arteries I66.09 Occlusion and stenosis of unspecified middle cerebral artery I66.11 Occlusion and stenosis of right anterior cerebral artery I66.12 Occlusion and stenosis of left anterior cerebral artery I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries I66.19 Occlusion and stenosis of unspecified anterior cerebral artery I66.21 Occlusion and stenosis of right posterior cerebral artery I66.22 Occlusion and stenosis of left posterior cerebral artery I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries I66.29 Occlusion and stenosis of unspecified posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries I66.9 Occlusion and stenosis of unspecified cerebral artery I67.841 Reversible cerebrovascular vasoconstriction syndrome I67.848 Other cerebrovascular vasospasm and vasoconstriction I97.0 Postcardiotomy syndrome I97.110 Postprocedural cardiac insufficiency following I97.111 Postprocedural cardiac insufficiency following other surgery I97.120 Postprocedural cardiac arrest following cardiac surgery I97.121 Postprocedural cardiac arrest following other surgery I97.130 Postprocedural heart failure following cardiac surgery I97.131 Postprocedural heart failure following other surgery I97.190 Other postprocedural cardiac functional disturbances following cardiac surgery I97.191 Other postprocedural cardiac functional disturbances following other surgery R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified R06.01 Orthopnea R06.02 Shortness of breath R06.09 Other forms of dyspnea R06.1 Stridor R06.2 Wheezing R06.3 Periodic breathing R06.4 Hyperventilation R06.81 Apnea, not elsewhere classified

Policy No. MP-053-MC-ALL Page 15 of 24 R06.82 Tachypnea, not elsewhere classified R06.83 Snoring R06.89 Other abnormalities of breathing R07.2 Precordial pain R07.82 Intercostal pain R07.89 Other chest pain R07.9 Chest pain, unspecified R29.5 Transient paralysis R40.4 Transient alteration of awareness R42 Dizziness and giddiness R55 Syncope and collapse T46.0x5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounter T46.0X5D Adverse effect of cardiac-stimulant glycosides and drugs of similar action, subsequent encounter T46.0x5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequela T46.1x5A Adverse effect of calcium-channel blockers, initial encounter T46.1X5D Adverse effect of calcium-channel blockers, subsequent encounter T46.1x5S Adverse effect of calcium-channel blockers, sequela T46.2x5A Adverse effect of other antidysrhythmic drugs, initial encounter T46.2X5D Adverse effect of other antidysrhythmic drugs, subsequent encounter T46.2x5S Adverse effect of other antidysrhythmic drugs, sequela T46.905A Adverse effect of unspecified agents primarily affecting the cardiovascular system, initial encounter T46.905S Adverse effect of unspecified agents primarily affecting the cardiovascular system, sequela T46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounter T46.995S Adverse effect of other agents primarily affecting the cardiovascular system, sequela T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter T82.110S Breakdown (mechanical) of cardiac electrode, sequela T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter T82.111D Breakdown (mechanical) of cardiac pulse generator (battery), subsequent encounter T82.111S Breakdown (mechanical) of cardiac pulse generator (battery), sequela T82.120A Displacement of cardiac electrode, initial encounter T82.120D Displacement of cardiac electrode, subsequent encounter T82.120S Displacement of cardiac electrode, sequela T82.121A Displacement of cardiac pulse generator (battery), initial encounter T82.121D Displacement of cardiac pulse generator (battery), subsequent encounter T82.121S Displacement of cardiac pulse generator (battery), sequela T82.190A Other mechanical complication of cardiac electrode, initial encounter T82.190D Other mechanical complication of cardiac electrode, subsequent encounter

Policy No. MP-053-MC-ALL Page 16 of 24 T82.190S Other mechanical complication of cardiac electrode, sequela T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter T82.191D Other mechanical complication of cardiac pulse generator (battery), subsequent encounter T82.191S Other mechanical complication of cardiac pulse generator (battery), sequela Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z51.81 Encounter for therapeutic drug monitoring Z79.02 Long term (current) use of antithrombotics/antiplatelets Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID) Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z95.0 Presence of cardiac pacemaker Z95.810 Presence of automatic (implantable) cardiac defibrillator Z95.818 Presence of other cardiac implants and grafts Z95.9 Presence of cardiac and vascular implant and graft, unspecified

Covered Diagnosis Codes For Procedure Codes 93268, 93270, 93271, 93272 ICD-10 Description Codes G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.8 Other transient cerebral ischemic attacks and related syndromes G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

Policy No. MP-053-MC-ALL Page 17 of 24 I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I24.9 Acute ischemic heart disease, unspecified I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris I25.2 Old myocardial infarction I25.5 I25.6 Silent myocardial ischemia I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris

Policy No. MP-053-MC-ALL Page 18 of 24 I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris I25.82 Chronic total occlusion of coronary artery I25.89 Other forms of chronic ischemic heart disease I25.9 Chronic ischemic heart disease, unspecified I34.0 Nonrheumatic mitral (valve) insufficiency I34.1 Nonrheumatic mitral (valve) prolapse I34.2 Nonrheumatic mitral (valve) stenosis I34.8 Other nonrheumatic mitral valve disorders I34.9 Nonrheumatic mitral valve disorder, unspecified I35.0 Nonrheumatic aortic (valve) stenosis I35.1 Nonrheumatic aortic (valve) insufficiency I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency I35.8 Other nonrheumatic aortic valve disorders I35.9 Nonrheumatic aortic valve disorder, unspecified I42.0 Dilated cardiomyopathy I42.5 Other restrictive cardiomyopathy I42.8 Other cardiomyopathies I42.9 Cardiomyopathy, unspecified I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree I44.2 Atrioventricular block, complete I44.30 Unspecified atrioventricular block

Policy No. MP-053-MC-ALL Page 19 of 24 I44.39 Other atrioventricular block I44.4 Left anterior fascicular block I44.5 Left posterior fascicular block I44.60 Unspecified fascicular block I44.69 Other fascicular block I44.7 Left bundle-branch block, unspecified I45.0 Right fascicular block I45.10 Unspecified right bundle-branch block I45.19 Other right bundle-branch block I45.2 Bifascicular block I45.3 Trifascicular block I45.4 Nonspecific intraventricular block I45.5 Other specified heart block I45.6 Pre-excitation syndrome I45.81 Long QT syndrome I45.89 Other specified conduction disorders I45.9 Conduction disorder, unspecified I46.2 Cardiac arrest due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.91 Unspecified atrial fibrillation I48.92 Unspecified atrial flutter I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.1 Atrial premature depolarization I49.2 Junctional premature depolarization I49.3 Ventricular premature depolarization I49.40 Unspecified premature depolarization I49.49 Other premature depolarization I49.5 Sick sinus syndrome I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure

Policy No. MP-053-MC-ALL Page 20 of 24 I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I63.40 Cerebral infarction due to embolism of unspecified cerebral artery I63.411 Cerebral infarction due to embolism of right middle cerebral artery I63.412 Cerebral infarction due to embolism of left middle cerebral artery I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery I63.421 Cerebral infarction due to embolism of right anterior cerebral artery I63.422 Cerebral infarction due to embolism of left anterior cerebral artery I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery I63.431 Cerebral infarction due to embolism of right posterior cerebral artery I63.432 Cerebral infarction due to embolism of left posterior cerebral artery I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery I63.441 Cerebral infarction due to embolism of right cerebellar artery I63.442 Cerebral infarction due to embolism of left cerebellar artery I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other cerebral artery I66.01 Occlusion and stenosis of right middle cerebral artery I66.02 Occlusion and stenosis of left middle cerebral artery I66.03 Occlusion and stenosis of bilateral middle cerebral arteries I66.09 Occlusion and stenosis of unspecified middle cerebral artery I66.11 Occlusion and stenosis of right anterior cerebral artery I66.12 Occlusion and stenosis of left anterior cerebral artery I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries I66.19 Occlusion and stenosis of unspecified anterior cerebral artery I66.21 Occlusion and stenosis of right posterior cerebral artery I66.22 Occlusion and stenosis of left posterior cerebral artery I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries I66.29 Occlusion and stenosis of unspecified posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries I66.9 Occlusion and stenosis of unspecified cerebral artery I67.841 Reversible cerebrovascular vasoconstriction syndrome

Policy No. MP-053-MC-ALL Page 21 of 24 I67.848 Other cerebrovascular vasospasm and vasoconstriction R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified R06.01 Orthopnea R06.02 Shortness of breath R06.09 Other forms of dyspnea R06.1 Stridor R06.2 Wheezing R06.3 Periodic breathing R06.4 Hyperventilation R06.81 Apnea, not elsewhere classified R06.82 Tachypnea, not elsewhere classified R06.83 Snoring R06.89 Other abnormalities of breathing R07.2 Precordial pain R07.82 Intercostal pain R07.89 Other chest pain R07.9 Chest pain, unspecified R29.5 Transient paralysis R40.4 Transient alteration of awareness R42 Dizziness and giddiness R55 Syncope and collapse T46.0x5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounter T46.0X5D Adverse effect of cardiac-stimulant glycosides and drugs of similar action, subsequent encounter T46.0x5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequela T46.1x5A Adverse effect of calcium-channel blockers, initial encounter T46.1X5D Adverse effect of calcium-channel blockers, subsequent encounter T46.1x5S Adverse effect of calcium-channel blockers, sequela T46.2x5A Adverse effect of other antidysrhythmic drugs, initial encounter T46.2X5D Adverse effect of other antidysrhythmic drugs, subsequent encounter T46.2x5S Adverse effect of other antidysrhythmic drugs, sequela T46.905A Adverse effect of unspecified agents primarily affecting the cardiovascular system, initial encounter T46.905S Adverse effect of unspecified agents primarily affecting the cardiovascular system, sequela T46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounter T46.995S Adverse effect of other agents primarily affecting the cardiovascular system, sequela T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter

Policy No. MP-053-MC-ALL Page 22 of 24 T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter T82.110S Breakdown (mechanical) of cardiac electrode, sequela T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter T82.111D Breakdown (mechanical) of cardiac pulse generator (battery), subsequent encounter T82.111S Breakdown (mechanical) of cardiac pulse generator (battery), sequela T82.120A Displacement of cardiac electrode, initial encounter T82.120D Displacement of cardiac electrode, subsequent encounter T82.120S Displacement of cardiac electrode, sequela T82.121A Displacement of cardiac pulse generator (battery), initial encounter T82.121D Displacement of cardiac pulse generator (battery), subsequent encounter T82.121S Displacement of cardiac pulse generator (battery), sequela T82.190A Other mechanical complication of cardiac electrode, initial encounter T82.190D Other mechanical complication of cardiac electrode, subsequent encounter T82.190S Other mechanical complication of cardiac electrode, sequela T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter T82.191D Other mechanical complication of cardiac pulse generator (battery), subsequent encounter T82.191S Other mechanical complication of cardiac pulse generator (battery), sequela Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z51.81 Encounter for therapeutic drug monitoring Z79.02 Long term (current) use of antithrombotics/antiplatelets Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID) Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z86.74 Personal history of sudden cardiac arrest Z95.0 Presence of cardiac pacemaker Z95.9 Presence of cardiac and vascular implant and graft, unspecified

REIMBURSEMENT Participating facilities will be reimbursed per their Gateway Health℠ contract.

POLICY SOURCE(S)

Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual, Chapter 1, Part 1 (Sections 10 – 80.12); Coverage Determinations (rev. 201, 07-28-17); 20.15-Electrocardiographic Services (Rev. 173, Issued: 09-04-14. Effective: Upon Implementation: ICD-10, Implementation: Upon Implementation of ICD-10). Accessed on November 7, 2017 and available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf

Policy No. MP-053-MC-ALL Page 23 of 24 Centers for Medicare and Medicaid Services (CMS), National Coverage Determination (LCD). No. L34953: Cardiac Event Detection Monitoring. Effective 10/01/2015. Accessed on March 6, 2018 and available at: S:\Medical Policy Development\MEDICARE POLICIES\PA Medicare Medical Policies\2018 PA Medicare Medical Policies\MP-054-MC-PA Cardiac Event Detection\Research and Information\Local Coverage Determination for Cardiac Event Detection Monitoring (L34953)_aspx.mht

Title XVIII of the Social Security Act, Section 1862(a)(1)(A).

Title XVIII of the Social Security Act, Section 1862(a)(7).

Title XVIII of the Social Security Act, Section 1862(a)(1)(D).

Title XVIII of the Social Security Act, Section 1833(e).

Medicare Benefit Policy Manual - Pub. 100-02.

Medicare National Coverage Determinations Manual - Pub. 100-03, Chapter 1, Section 20.15; Effective 08/26/2004; Revision 09/04/2014.

Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodin ited/

CMS OLM, 100-09, Chapter 5. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS019034.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

Policy History

Date Activity 10/31/2017 Initial policy developed 03/21/2018 QI/UM Committee approval 06/01/2018 Provider effective date

Policy No. MP-053-MC-ALL Page 24 of 24