Medicare Benefits Schedule - Item 38285

Insertion of implantable ECG loop recorder, by a specialist or consultant physician, for the diagnosis of a primary disorder, including initial programming and testing, if:

(a) the patient has recurrent unexplained syncope and does not have a structural heart defect associated with a high risk of sudden cardiac death; and

(b) a diagnosis has not been achieved through all other available cardiac investigations; and

(c) a neurogenic cause is not suspected

Multiple Operation Rule

(Anaes.)

Fee: $169.80 Benefit: 75% = $127.35 85% = $144.35

(See para TN.8.61, TN.8.211 of explanatory notes to this Category)

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The fee for implantation of the loop recorder (item 38285) covers the initial programming and testing of the device for satisfactory rhythm capture. Benefits are payable only once per day. 

The term "recurrent" refers to more than one episode of syncope, where events occur at intervals of 1 week or longer. The term "other available cardiac investigations" includes the following:

• a complete history and physical examination that excludes a primary neurological cause of syncope and does not exclude a cardiac cause;
• electrocardiography (ECG) (items 11704, 11705, 11707, 11714);
• echocardiography (items 55126, 55127, 55128, 55129, 55132, 55133, 55134);
• continuous ECG recording or ambulatory ECG monitoring (items 11716, 11717, 11723, 11735);
• up-right tilt table test (item 11724); and
• cardiac electrophysiological study, unless there is reasonable medical reason to waive this requirement (item 38209).

Related Items: 38285

Claiming Guidance

• The service to which item 38285 applies may be claimed for the insertion of an implanted loop recorder (ILR) rendered to a patient as part of an episode of hospital treatment, including services provided in hospital outpatient settings.
• Private health insurers are required to pay benefits for products listed on the Prostheses List, if the product is rendered to a patient with the appropriate level of cover, as part of an episode of hospital treatment or hospital substitute treatment.
• When the ILR is inserted in the outpatient setting (the specialist or consultant physicians private rooms/clinic) the private insurer may opt to cover the cost of the device, but is not required to do so.

Related Items: 38285 38286