Cardiac Ablation Procedures

Policy ID: M-18-034

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: September 15, 2022

Revision Effective Date: October 01, 2022

Last Reviewed: September 12, 2023

Applies To: Commercial and Medicaid Expansion

Description

Catheter ablation is a therapeutic technique using a cryoballoon to eliminate conduction defects.

Maze or Modified Maze Procedures, also known as (a.k.a.) surgical ablation, are performed on a non-beating heart during the cardiopulmonary bypass to destroy the arrhythmic area of the heart.

Hybrid catheter and surgical ablation (HyCASA) is a minimally-invasive procedure for treatment of atrial fibrillation. The procedure combines thoroscopic epicardial ablation performed by a surgeon and percutaneous endocardial ablation performed by an electrophysiologist as directed by the electrophysiology study. It is performed either as part of a single "joint" procedure or as two (2) separate ablation procedures.

Criteria

Catheter Ablation Procedures

Intracardiac catheter ablation of atrioventricular node (AV) function may be considered medically necessary for ANY of the following indications:

Atrial ablation for elimination of atrial fibrillation; or
Atrial tachycardia or atrial flutter; or
Paroxysmal supraventricular tachycardia; or
Radiofrequency catheter ablation or modification of the atrioventricular junction for ventricular rate control of symptomatic atrial tachyarrhythmias; or
Symptomatic sustained atrioventricular nodal reentrant tachycardia.

Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters may be considered medically necessary for ANY of the following indications:

For treatment of individuals with supraventricular tachycardia with ANY of the following indications:
- Accessory bypass tract arrhythmia (Wolff-Parkinson-White Syndrome); or
- Atrial ablation for elimination of atrial fibrillation; or
- Atrial tachycardia or atrial flutter; or
- Paroxysmal supraventricular tachycardia; or
- Supraventricular tachycardia; or
- Symptomatic sustained atrioventricular nodal reentrant tachycardia; or

For treatment of individuals with ventricular tachycardia with ANY of the following indications:
- Bundle branch reentrant ventricular tachycardia; or
- Individuals without structural heart disease (i.e., ischemic or idiopathic cardiomyopathy) with symptomatic sustained monomorphic ventricular tachycardia; or
- Ischemic or idiopathic cardiomyopathy with ventricular tachycardia

A catheter ablation procedure not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

93650

93653

93654

93655

93656

93657

Transcatheter Radiofrequency Ablation or Cryoablation

Transcatheter radiofrequency ablation or cryoablation to treat atrial fibrillation in individuals who have failed to respond to adequate trials of antiarrhythmic medications may be considered medically necessary for ANY of the following indications:

As an alternative to atrioventricular nodal ablation and pacemaker insertion in individuals with class II or III congestive heart failure and symptomatic atrial fibrillation; or
As an initial treatment for individuals with recurrent symptomatic paroxysmal atrial fibrillation (greater than one (1) episode, with less than or equal to four (4) episodes in the previous six (6) months) in whom a rhythm-control strategy is desired; or
Symptomatic paroxysmal atrial fibrillation; or
Symptomatic persistent atrial fibrillation.

Repeat transcatheter radiofrequency ablation or cryoablation may be considered medically necessary; in individuals with ANY of the following:

Development of atrial flutter following the initial procedure; or
Recurrence of atrial fibrillation.

Transcatheter radiofrequency ablation or cryoablation not meeting the criteria as indicated this policy is considered experimental/investigational.

Procedure Codes

93655

93656

93657

Operative Ablation Procedures

Operative ablation of supraventricular arrhythmogenic focus or pathway may be considered medically necessary to eliminate artrioventricular conduction defects.

Operative ablation of supraventricular arrhythmogenic focus or pathway not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33250

33251

33261

Maze Procedures

The maze and modified maze procedures performed on a non-beating heart during cardiopulmonary bypass with concomitant cardiac surgery may be considered medically necessary for treatment of individuals with atrial fibrillation or flutter.

The maze or modified maze procedure performed on a non‒beating heart during cardiopulmonary bypass without concomitant cardiac surgery is considered not medically necessary for treatment of individuals with atrial fibrillation or flutter.

The use of an open maze procedures or modified maze procedure not meeting the criteria indicated in this policy is considered not medically necessary.

Stand-alone minimally invasive, off-pump maze procedures (i.e., modified maze procedures), including those done via mini-thoracotomy, for treatment of individuals with atrial fibrillation or flutter are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

33254

33255

33256

33257

33258

33259

Hybrid and Surgical Ablation (HyCASA)

HyCASA procedures may be considered medically necessary when ALL of the following criteria are met:

The cardiothoracic (CT) surgeon has experience in treating arrhythmias surgically (at least 50 cases); and
The facility has a suite that can accommodate the Hybrid procedure requirements; and
The individual has one (1) of the following:
- Inability to proceed with a standard PVI from an endocardial approach (i.e. esophageal heating); or
- Previous failed pulmonary vein isolation (PVI); and
The individual has persistent difficult-to-treat drug resistant atrial fibrillation greater than six (6) months; and
The surgeon and electrophysiologist both agree that the individual would be an appropriate candidate for the procedure; and
There is a presence of structural heart disease (e.g. left atrial enlargement and/or left ventricular dysfunction).

Hybrid catheter and surgical ablation (HyCASA) procedure not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33265

33266

93613

93620

93655

93656

93657

93662

Outpatient HCPCS

C1732

C1733

C2630

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 93613

I47.1

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Code 93650

I45.89

I47.1

I47.9

I48.0

I48.11

I48.19

I48.20

I48.21

I48.91

I49.2

I49.8

R00.1

Covered Diagnosis Codes for Procedure Codes 93653

I25.5

I25.6

I25.89

I25.9

I42.0

I42.2

I42.5

I42.8

I42.9

I45.6

I45.81

I45.89

I47.1

I47.9

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.2

I49.8

R00.1

Covered Diagnosis Codes for Procedure Code 93654

I25.5

I25.6

I25.89

I25.9

I42.0

I42.2

I42.5

I42.8

I42.9

I47.0

I47.20

I47.29

I48.91

I49.1

I49.3

I49.40

I49.49

Covered Diagnosis Codes for Procedure Code 93655

I45.6

I45.89

I47.0

I47.1

I47.20

I47.29

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.01

I49.02

I49.1

I49.2

I49.3

I49.5

I49.8

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Codes 93656 and 93657

I25.5

I45.6

I45.89

I47.0

I47.1

I47.20

I47.29

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.01

I49.02

I49.1

I49.2

I49.3

I49.5

I49.8

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Codes 93662

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Code 33250, 33251, and 33261

I44.0

I44.1

I44.2

I44.30

Covered Diagnosis Codes for Procedure Codes 33254, 33255, 33256, 33257, 33258 and 33259

I45.6

I47.1

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.8

I48.91

I48.92

I49.2

I49.3

I49.40

I49.49

I49.8

Covered Diagnosis Codes for Procedure Codes 33265 and 33266

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Professional Statements and Societal Positions Guidelines

American College of Cardiology et al - 2019

In 2014, the American College of Cardiology, American Heart Association, and Heart Rhythm Society

(ACC/AHA/HRS) issued guidelines for the management of individuals with AF. In 2019, the AHA/ACC/HRS conducted a focused update of areas for which new evidence had emerged since the 2014 publication. Together, the guidelines included the following recommendations for rate control and rhythm control:

Rate Control:
- AV nodal ablation with permanent ventricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is not achievable.
- AV nodal ablation with permanent ventricular pacing should not be performed to improve rate control without prior attempts to achieve rate control with medications.
Rhythm Control:
- AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication when a rhythm-control strategy is desired.
- Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual is recommended.
- AF catheter ablation is reasonable for some individuals with symptomatic persistent AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication.
- In individuals with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy.
- AF catheter ablation may be considered for symptomatic long-standing (greater than or equal to 12 months) persistent AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication when a rhythm-control strategy is desired).
- AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired.
- AF catheter ablation should not be performed in individuals who cannot be treated with anticoagulant therapy during and after the procedure.
- AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation."
- AF catheter ablation may be reasonable in selected individuals with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF

Although the guidelines did not make a specific recommendation on the use of cryoablation, they did state:

Cryoballoon ablation is an alternative to point-by-point radiofrequency ablation to achieve pulmonary vein isolation.

Society of Thoracic Surgeons – 2017

In 2017, the Society of Thoracic Surgeons published guidelines on the surgical treatment of atrial fibrillation (AF). Recommendations are as follows:

Surgical ablation for AF is recommended at the time of concomitant mitral operations to restore sinus rhythm.
Surgical ablation for AF is recommended at the time of concomitant isolated aortic valve replacement, isolated CABG surgery, and aortic valve replacement plus CABG operations to restore sinus rhythm.
Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy of both is reasonable as a primary stand-alone procedure to restore sinus rhythm.

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Multiple Revisions

Internal Medical Policy Committee 5-20-2021 Revision

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding update

Added Procedure codes: 93656; and 93620
Added Outpatient HCPCS: C1732; C1733 and C2630
Added Diagnosis codes I45.6; I45.89; I47.0; I47.1; I47.2; I48.0; I48.91; I48.92; I49.2; I49.3; I49.40; I49.49; I49.5; I49.8; I50.1; and I51.7

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Removed Diagnosis code I47.2
Added Diagnosis codes I47.20 and I47.29

Internal Medical Policy Committee 9-12-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-18-033

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: June 09, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 21, 2022

Archived Date: September 30, 2022

Applies To: Commercial and Medicaid Expansion

Description

Catheter ablation is a therapeutic technique using a cryoballoon to eliminate conduction defects.

Maze or Modified Maze Procedures, also known as (a.k.a.) surgical ablation, are performed on a non-beating heart during the cardiopulmonary bypass to destroy the arrhythmic area of the heart.

Criteria

Catheter Ablation Procedures

Intracardiac catheter ablation of atrioventricular node (AV) function may be considered medically necessary for ANY of the following indications:

Atrial ablation for elimination of atrial fibrillation; or
Atrial tachycardia or atrial flutter; or
Paroxysmal supraventricular tachycardia; or
Radiofrequency catheter ablation or modification of the atrioventricular junction for ventricular rate control of symptomatic atrial tachyarrhythmias; or
Symptomatic sustained atrioventricular nodal reentrant tachycardia.

Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters may be considered medically necessary for ANY of the following indications:

For treatment of individuals with supraventricular tachycardia with ANY of the following indications:
- Accessory bypass tract arrhythmia (Wolff-Parkinson-White Syndrome); or
- Atrial ablation for elimination of atrial fibrillation; or
- Atrial tachycardia or atrial flutter; or
- Paroxysmal supraventricular tachycardia; or
- Supraventricular tachycardia; or
- Symptomatic sustained atrioventricular nodal reentrant tachycardia; or

For treatment of individuals with ventricular tachycardia with ANY of the following indications:
- Bundle branch reentrant ventricular tachycardia; or
- Individuals without structural heart disease (i.e., ischemic or idiopathic cardiomyopathy) with symptomatic sustained monomorphic ventricular tachycardia; or
- Ischemic or idiopathic cardiomyopathy with ventricular tachycardia

A catheter ablation procedure not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

93650

93653

93654

93655

93656

93657

Transcatheter Radiofrequency Ablation or Cryoablation

As an alternative to atrioventricular nodal ablation and pacemaker insertion in individuals with class II or III congestive heart failure and symptomatic atrial fibrillation; or
As an initial treatment for individuals with recurrent symptomatic paroxysmal atrial fibrillation (greater than one (1) episode, with less than or equal to four (4) episodes in the previous six (6) months) in whom a rhythm-control strategy is desired; or
Symptomatic paroxysmal atrial fibrillation; or
Symptomatic persistent atrial fibrillation.

Repeat transcatheter radiofrequency ablation or cryoablation may be considered medically necessary; in individuals with ANY of the following:

Development of atrial flutter following the initial procedure; or
Recurrence of atrial fibrillation.

Transcatheter radiofrequency ablation or cryoablation not meeting the criteria as indicated this policy is considered experimental/investigational.

Procedure Codes

93655

93656

93657

Operative Ablation Procedures

Operative ablation of supraventricular arrhythmogenic focus or pathway may be considered medically necessary to eliminate artrioventricular conduction defects.

Operative ablation of supraventricular arrhythmogenic focus or pathway not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33250

33251

33261

Maze Procedures

The use of an open maze procedures or modified maze procedure not meeting the criteria indicated in this policy is considered not medically necessary.

Procedure Codes

33254

33255

33256

33257

33258

33259

Hybrid and Surgical Ablation (HyCASA)

HyCASA procedures may be considered medically necessary when ALL of the following criteria are met:

The cardiothoracic (CT) surgeon has experience in treating arrhythmias surgically (at least 50 cases); and
The facility has a suite that can accommodate the Hybrid procedure requirements; and
The individual has one (1) of the following:
- Inability to proceed with a standard PVI from an endocardial approach (i.e. esophageal heating); or
- Previous failed pulmonary vein isolation (PVI); and
The individual has persistent difficult-to-treat drug resistant atrial fibrillation greater than six (6) months; and
The surgeon and electrophysiologist both agree that the individual would be an appropriate candidate for the procedure; and
There is a presence of structural heart disease (e.g. left atrial enlargement and/or left ventricular dysfunction).

Hybrid catheter and surgical ablation (HyCASA) procedure not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

33265

33266

93613

93620

93655

93656

93657

93662

Outpatient HCPCS

C1732

C1733

C2630

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 93613

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Code 93650

I45.89

I47.1

I47.9

I48.0

I48.11

I48.19

I48.20

I48.21

I48.91

I49.2

I49.8

R00.1

Covered Diagnosis Codes for Procedure Codes 93653

I25.5

I25.6

I25.89

I25.9

I42.0

I42.2

I42.5

I42.8

I42.9

I45.6

I45.81

I45.89

I47.1

I47.9

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.2

I49.8

R00.1

Covered Diagnosis Codes for Procedure Code 93654

I25.5

I25.6

I25.89

I25.9

I42.0

I42.2

I42.5

I42.8

I42.9

I47.0

I47.2

I48.91

I49.1

I49.3

I49.40

I49.49

Covered Diagnosis Codes for Procedure Code 93655

I45.6

I45.89

I47.0

I47.1

I47.2

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.01

I49.02

I49.1

I49.2

I49.3

I49.5

I49.8

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Codes 93656 and 93657

I25.5

I45.6

I45.89

I47.0

I47.1

I47.2

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.91

I48.92

I49.01

I49.02

I49.1

I49.2

I49.3

I49.5

I49.8

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Codes 93662

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Covered Diagnosis Codes for Procedure Code 33250, 33251, and 33261

I44.0

I44.1

I44.2

I44.30

Covered Diagnosis Codes for Procedure Codes 33254, 33255, 33256, 33257, 33258 and 33259

I45.6

I47.1

I48.0

I48.11

I48.19

I48.20

I48.21

I48.3

I48.4

I48.8

I48.91

I48.92

I49.2

I49.3

I49.40

I49.49

I49.8

Covered Diagnosis Codes for Procedure Codes 33265 and 33266

I48.11

I48.19

I48.20

I48.21

I49.01

I49.02

I49.1

I49.2

I49.3

I49.49

I49.9

I50.1

I51.7

Professional Statements and Societal Positions Guidelines

American College of Cardiology et al - 2019

In 2014, the American College of Cardiology, American Heart Association, and Heart Rhythm Society

Rate Control:
- AV nodal ablation with permanent ventricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is not achievable.
- AV nodal ablation with permanent ventricular pacing should not be performed to improve rate control without prior attempts to achieve rate control with medications.
Rhythm Control:
- AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication when a rhythm-control strategy is desired.
- Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual is recommended.
- AF catheter ablation is reasonable for some individuals with symptomatic persistent AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication.
- In individuals with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy.
- AF catheter ablation may be considered for symptomatic long-standing (greater than or equal to 12 months) persistent AF refractory or intolerant to at least one (1) class I or III antiarrhythmic medication when a rhythm-control strategy is desired).
- AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired.
- AF catheter ablation should not be performed in individuals who cannot be treated with anticoagulant therapy during and after the procedure.
- AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation."
- AF catheter ablation may be reasonable in selected individuals with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF

Although the guidelines did not make a specific recommendation on the use of cryoablation, they did state:

Cryoballoon ablation is an alternative to point-by-point radiofrequency ablation to achieve pulmonary vein isolation.

Society of Thoracic Surgeons – 2017

In 2017, the Society of Thoracic Surgeons published guidelines on the surgical treatment of atrial fibrillation (AF). Recommendations are as follows:

Surgical ablation for AF is recommended at the time of concomitant mitral operations to restore sinus rhythm.
Surgical ablation for AF is recommended at the time of concomitant isolated aortic valve replacement, isolated CABG surgery, and aortic valve replacement plus CABG operations to restore sinus rhythm.
Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy of both is reasonable as a primary stand-alone procedure to restore sinus rhythm.

ND Committee Review

Internal Medical Policy Committee 11-19-20 Multiple Revisions

Internal Medical Policy Committee 5-20-2021 Revision

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in critera

Internal Medical Policy Committee 7-21-2022 Revision with coding update

Added Procedure codes: 93656; and 93620
Added Outpatient HCPCS: C1732; C1733 and C2630
Added Diagnosis codes I45.6; I45.89; I47.0; I47.1; I47.2; I48.0; I48.91; I48.92; I49.2; I49.3; I49.40; I49.49; I49.5; I49.8; I50.1; and I51.7

Links

References (PDF)

Disclaimer

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