Transtelephonic Monitoring of Cardiac Pacemakers

CMS National Coverage Determination | ncd_id=345 | manual_section=20.8.1.1 | coverage_level_code=1 | national_coverage_type=True | under_review=True | lab_ncd=False

B. Definition of Transtelephonic Monitoring In order for transtelephonic monitoring services to be covered, the services must consist of the following elements: A minimum 30-second readable strip of the pacemaker in the free-running mode; Unless contraindicated, a minimum 30-second readable strip of the pacemaker in the magnetic mode; and A minimum 30 seconds of readable ECG strip. C. Frequency Guidelines for Transtelephonic Monitoring The guidelines below constitute a system which Medicare Administrative Contractors (MACs) should use, in conjunction with their knowledge of local medical practices, to screen claims for transtelephonic monitoring prior to payment. It is important to note that they are not recommendations with respect to a minimum frequency for such monitorings, but rather a maximum frequency (within which payment may be made without further claims development). As with previous guidelines, more frequent monitorings may be covered in cases where MACs are satisfied that such monitorings are medically necessary; e.g., based on the condition of the patient, or with respect to pacemakers exhibiting unexpected defects or premature failure. MACs should seek written justification for more frequent monitorings from the patient’s physician and/or any monitoring service involved. These guidelines are divided into two broad categories - Guideline I which will apply to the majority of pacemakers now in use, and Guideline II which will apply only to pacemaker systems (pacemaker and leads) for which sufficient long-term clinical information exists to assure that they meet the standards of the Inter-Society Commission for Heart Disease Resources (ICHD) for longevity and end-of-life decay. (The ICHD standards are: (1) 90% cumulative survival at 5 years following implant; and (2) an end-of-life decay of less than a 50% drop of output voltage and less than 20% deviation of magnet rate, or a drop of 5 beats per minute or less, over a period of 3 months or more.) MACs should consult with their medical advisers and other appropriate individuals and organizations (such as the North American Society of Pacing and Electrophysiology which publishes product reliability information) should questions arise over whether a pacemaker system meets the ICHD standards. The two groups of guidelines are then further broken down into two general categories – single-chamber and dual-chamber pacemakers. MACs should be aware that the frequency with which a patient is monitored may be changed from time-to-time for a number of reasons, such as a change in the patient’s overall condition, a reprogramming of the patient’s pacemaker, the development of better information on the pacemaker’s longevity or failure mode, etc. Consequently, changes in the proper set of guidelines may be required. MACs should inform physicians and monitoring services to alert MACs to any changes in the patient’s monitoring prescription that might necessitate changes in the screening guidelines applied to that patient. (Of particular importance is the reprogramming of a dual-chamber pacemaker to a single-chamber mode of operation. Such reprogramming would shift the patient from the appropriate dual-chamber guideline to the appropriate single-chamber guideline.) Such reprogramming would shift the patient from the appropriate dual-chamber guideline to the appropriate single-chamber guideline.) Guideline I 1 - Single-chamber pacemakers 1st month - every 2 weeks. 2nd through 36th month - every 8 weeks. 37th month to failure - every 4 weeks. 2 - Dual-chamber pacemaker 1st month - every 2 weeks. 2nd through 6th month - every 4 weeks. 7th through 36th month - every 8 weeks. 37th month to failure - every 4 weeks. Guideline II 1 - Single-chamber pacemakers 1st month - every 2 weeks. 2nd through 48th month - every 12 weeks. 49th through 72nd month - every 8 weeks. Thereafter - every 4 weeks. 2 - Dual-chamber pacemaker 1st month - every 2 weeks. 2nd through 30th month - every 12 weeks. 31st through 48th month - every 8 weeks. Thereafter - every 4 weeks. D. Pacemaker Clinic Services 1. General Pacemaker monitoring is also covered when done by pacemaker clinics. Clinic visits may be done in conjunction with transtelephonic monitoring or as a separate service; however, the services rendered by a pacemaker clinic are more extensive than those currently possible by telephone. They include, for example, physical examination of patients and reprogramming of pacemakers. Thus, the use of one of these types of monitoring does not preclude concurrent use of the other. 2. Frequency Guidelines As with transtelephonic pacemaker monitoring, the frequency of clinic visits is the decision of the patient’s physician, taking into account, among other things, the medical condition of the patient. However, MACs can develop monitoring guidelines that will prove useful in screening claims. The following are recommendations for monitoring guidelines on lithium-battery pacemakers: For single-chamber pacemakers - twice in the first 6 months following implant, then once every 12 months. For dual-chamber pacemakers - twice in the first 6 months, then once every 6 months.

Item/Service Description: A. General Transtelephonic monitoring of pacemakers is furnished by commercial suppliers, hospital outpatient departments, and physicians’ offices. Telephone monitoring of cardiac pacemakers as described below is medically efficacious in identifying early signs of possible pacemaker failure, thus reducing the number of sudden pacemaker failures requiring emergency replacement. All systems that monitor the pacemaker rate (bpm) in both the free-running and/or magnetic mode are effective in detecting subclinical pacemaker failure due to battery depletion. More sophisticated systems are also capable of detecting internal electronic problems within the pulse generator itself and other potential problems. In the case of dual-chamber pacemakers in particular, such monitoring may detect failure of synchronization of the atria and ventricles, and the need for adjustment and reprogramming of the device. NOTE: The transmitting device furnished to the patient is simply one component of the diagnostic system, and is not covered as durable medical equipment. Those engaged in transtelephonic pacemaker monitoring should reflect the costs of the transmitters in setting their charges for monitoring. Benefit Categories: 46 - Outpatient Hospital Services Incident to a Physician's Service