Aetna considers Holter monitoring medically necessary for diagnostic evaluation of members with any of the following symptoms or conditions:

1. As a method to assess treatment effectiveness in individuals with baseline high frequency, reproducible, sustained, symptomatic premature ventricular complexes, supraventicular arrhythmias or ventricular tachycardia; or
2. Autonomic cardiac neuropathy associated with diabetes mellitus; or
3. Idiopathic hypertrophic or dilated cardiomyopathy; or
4. In individuals with pacemakers to assess paroxysmal symptoms, myopotential inhibition, pacemaker medicated tachycardia, anti-tachycardia pacing device functioning, rate-responsive physiologic pacing function; or
5. Individuals with pain suggestive of Prinzmetal's angina; or
6. Post myocardial infarction with left ventricular dysfunction; or
7. Symptoms related to rhythm disturbances (e.g., frequent palpitation, syncope, unexplained dizziness, frequent arrhythmias).

Aetna considers Holter monitoring experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Note: Digitalization and/or color display of results are considered incidental features of Holter monitoring.

Note: Holter monitoring lasting more than 48 hours is generally considered not medically necessary.  The literature indicates that if more frequent monitoring is needed to evaluate arrhythmias, use of cardiac event recorders should be considered.  See CPB 0073 - Cardiac Event Monitors.

Note: Routine performance of Holter monitoring has no proven benefit for individuals who are undergoing sleep studies for suspected obstructive sleep apnea.

Note: For Aetna's policy on home-based real-time cardiac surveillance systems (e.g., CardioNet Mobile Outpatient Cardiac Telemetry Service, Cardiac Telecom Telemetry @ Home Service), see CPB 0073 - Cardiac Event Monitors.

A Holter monitor is a self-contained ambulatory and recording device used to capture continuous electrocardiographic measurements over a period of 24 to 48 hours.  Holter monitors must be distinguished from ambulatory event monitors, which capture episodic electrocardiographic data over large periods of time, up to 1 month.

Electrodes are placed on the patient's chest and attached to a small recording monitor that the patient carries in a pocket or in a small pouch.  The monitor is battery operated.  A continuous electrocardiogram is recorded on a cassette tape, usually for a 24-hour period, while the patient keeps a diary of activities.  The recording is then analyzed, a report of the heart's activity is tabulated, and irregular heart activity is correlated with the patient's activity at the time.

Advanced Holter monitors have been developed that use digital electrocardiographic recordings, extended memory greater than 24 hours, pacemaker pulse detection and analysis, software for analysis of digital electrocardiographic recordings that are downloaded and stored on a computer, and capability of transmission of results over the internet (e.g., Raytel Medical Corporation, 2004; MIDMARK Diagnostics Group, 2004; Integrated Medical Devices, 2003).

Hegazy and Lotfy (2007) noted that Holter monitoring (HM) has been established as one of the most effective noninvasive clinical tools in the diagnosis, assessment and risk stratification of cardiac patients.  However, studies in the pediatric age group are limited.  These investigators at determined the value of HM in the diagnosis and management of children.  Holter records of 1,319 pediatric patients (54.1 % males and 45.9 % females) were reviewed.  Their average age was 6.7 +/- 4.1 years (5 days to 16 years).  Indications for which Holter monitoring was done were analyzed as well as all the abnormalities diagnosed and factors that may increase Holter yield.  Statistical Package of social science (SPSS) version 9,0 was used for analysis of data.  The most common indications were palpitations (19.8 %), syncope (17.8 %), cardiomyopathy (12.6 %), chest pain (10 %), evaluation of anti-arrhythmic therapy (6.8 %), post-operative assessment (2.6 %) and complete atrio-ventricular (AV) Block (2.4 %).  A  total of 141 Holter recordings were found abnormal with a total diagnostic yield of 10.7 %.  The highest contribution to diagnosis was in post-operative assessment (32.4 %) and in cardiomyopathy (19.9 %) where the most common abnormalities were frequent supra-ventricular/ventricular premature beats, supra-ventricular tachycardia, ventricular tachycardia and AV block.  Diagnostic yield was low in  patients with palpitations (5.7 %) and syncope (0.4 %).  An abnormal ECG was significantly associated with a higher diagnostic yield (p = 0.0001).  None of the children with chest pain had abnormal Holter recordings.  the authors concluded that HM has an extremely valuable role in the assessment of high-risk patients (post-operative and cardiomyopathy).  However in children with palpitations, syncope and chest pain HM has a low-yield.  In this group of patients an abnormal ECG is more likely to be associated with abnormal Holter recordings.