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Clinical Policy Bulletin:
Holter Monitors
Number: 0019


Policy

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.



Background

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. 

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
93224
93225
93226
93227
CPT codes not covered for indications listed in the CPB:
0295T - 0298T
ICD-9 codes covered if selection criteria are met:
250.60 - 250.63 Diabetes with neurological manifestations
306.2 Cardiovascular malfunction arising from mental factors
337.1 Peripheral autonomic neuropathy in disorders classified elsewhere
410.00 - 412 Myocardial infarction
413.1 Prinzmetal angina
425.1 Hypertrophic obstructive cardiomyopathy
425.4 Other primary cardiomyopathies
426.0 - 426.9 Conduction disorders
427.0 - 427.9 Cardiac dysrhythmias
435.0 - 435.9 Transient cerebral ischemia
780.2 Syncope and collapse
780.4 Dizziness and giddiness
785.1 Palpitations
V45.01 Cardiac pacemaker in situ
ICD-9 codes not covered for indications listed in the CPB:
327.00 - 327.8 Organic sleep disorders [if undergoing sleep studies for suspected obstructive sleep apnea]
780.50 - 780.59 Sleep disturbances [if undergoing sleep studies for suspected obstructive sleep apnea]
786.03 Apnea [if undergoing sleep studies for suspected obstructive sleep apnea]
786.09 Other dyspnea and respiratory abnormality [if undergoing sleep studies for suspected obstructive sleep apnea]


The above policy is based on the following references:
  1. Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997;126(12):989-996.
  2. Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997;127(1):76-86.
  3. Hayakawa H, Saitoh H. Advances in the diagnosis of arrhythmia Holter's ECG. Nippon Rinsho. 1996;54(8):2085-2090.
  4. Lantz DA. Efficacy of Holter monitors. Ann Intern Med. 1996;125(8):697-698.
  5. Sovova E, Doupal V, Lukl J. New trends in ECG Holter monitoring. Vnitr Lek. 1996;42(6):386-389.
  6. Farrehi PM, Santinga JT, Eagle KA. Syncope: Diagnosis of cardiac and noncardiac causes. Geriatrics. 1995;50(11):24-30.
  7. Wilson AC, Kostis JB. Duration of Holter monitoring. Am J Cardiol. 1994;74(3):308.
  8. Nakanishi T, Yoshimura M. Recent progress in Holter electrocardiography, focussed on heart rate variability. Rinsho Byori. 1993;41(11):1206-1213.
  9. DiMarco JP, Philbrick JT. Use of ambulatory electrocardiographic (Holter) monitoring. Ann Intern Med. 1990;113(1):53-68.
  10. McClennen S, Zimetbaum PJ, Ho KK, Goldberger AL. Holter monitoring: Are two days better than one? Am J Cardiol. 2000;86(5):562-564. 
  11. Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography: Executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 1999;100(8):886-893.
  12. Sivakumaran S, Krahn AD, Klein GJ, et al. A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope. Am J Med. 2003;115(1):1-5.
  13. Raytel Medical Corporation. Holter monitoring [website]. Raytel Cardiac Services. Turnersville, NJ: Raytel Diagnostic Services; 2004. Available at:http://www.raytel.com/Content.asp?CategoryID=27&CurrentID=123. Accessed January 11, 2005.
  14. MIDMARK Diagnostics Group. IQmark Advanced Holter Monitor. Torrance, CA: MIDMARK; 2004 Available at: http://midmarkdiagnostics.com/noflash/advance_holter.html. Accessed January 11, 2005.
  15. Integrated Medical Devices, Inc. Holter monitoring [website]. Liverpool, NY: Integrated Medical Devices; 2003. Available at: http://www.integrated-medical.com/holter.html. Accessed January 11, 2005.
  16. Scalvini S, Zanelli E, Martinelli G, et al. Cardiac event recording yields more diagnoses than 24-hour Holter monitoring in patients with palpitations. J Telemed Telecare. 2005;11 Suppl 1:14-16.
  17. British Columbia Ministry of Health, Guidelines and Protocols Advisory Committee. Ambulatory ECG Monitoring (Holter Monitor and Patient-Activated Event Recorder). Victoria, BC: British Columbia Ministry of Health; revised 2004. Available at: http://www.healthservices.gov.bc.ca/msp/protoguides. Accessed January 18, 2006.
  18. Aronow WS. Heart disease and aging. Med Clin North Am. 2006;90(5):849-862.
  19. Rajagopalan K, Potts JE, Sanatani S. Minimally invasive approach to the child with palpitations. Expert Rev Cardiovasc Ther. 2006;4(5):681-693.
  20. Gibson CM, Ciaglo LN, Southard MC, et al. Diagnostic and prognostic value of ambulatory ECG (Holter) monitoring in patients with coronary heart disease: A review. J Thromb Thrombolysis. 2007;23(2):135-145.
  21. Gibson CM, Pride YB, Buros JL, et al. Timing and duration of myocardial ischemia on Holter monitoring following percutaneous coronary intervention and their association with clinical outcomes (a PROTECT-TIMI 30 Substudy Analysis). Am J Cardiol. 2009;104(1):36-40.
  22. Pastor-Pérez FJ, Manzano-Fernández S, Goya-Esteban R, et al. Comparison of detection of arrhythmias in patients with chronic heart failure secondary to non-ischemic versus ischemic cardiomyopathy by 1 versus 7-day holter monitoring. Am J Cardiol. 2010;106(5):677-681.
  23. Alhadramy O, Jeerakathil TJ, Majumdar SR, et al. Prevalence and predictors of paroxysmal atrial fibrillation on Holter monitor in patients with stroke or transient ischemic attack. Stroke. 2010;41(11):2596-2600.
  24. Kuhne M, Schaer B, Sticherling C, Osswald S. Holter monitoring in syncope: Diagnostic yield in octogenarians. J Am Geriatr Soc. 2011;59(7):1293-1298.
  25. Hegazy RA, Lotfy WN. The value of Holter monitoring in the assessment of pediatric patients. Indian Pacing Electrophysiol. J. 2007;7(4):204-214.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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