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; I48.4; 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; and
- Added Diagnosis codes I47.20; and I47.29
Internal Medical Policy Committee 11-15-2023 Coding update - Effective October 01, 2023
- Removed Diagnosis code I47.1 from procedure codes 93613; 93650; 93653; 93655; 93656; 93657; 33254; 33255; 33256; 33257; 33258; and 33259.
- Added Diagnosis codes I47.10; I47.11; I47.19 to procedure codes 93650; 93653; 93655; 93656; 93657; 33254; 33255; 33256; 33257; 33258; and 33259.
Internal Medical Policy Committee 11-19-2024 Coding update - Effective January 06, 2025
- Added Policy Application; and
- Removed diagnosis code I47.1
Internal Medical Policy Committee 5-13-2025 Revision with Coding update - Effective July 07, 2025
- Removed procedure code 93656 from the 'Catheter Ablation Procedure' Section of the policy;and
- Added diagnosis codes I48.92 and I49.5 for procedure code 93650;and
- Added diagnosis codes I49.01 and I49.02 for procedure code 93654;and
- Added diagnosis code I47.9 forprocedurecode 93655;and
- Added diagnosis codes I25.5; I25.6; I25.9; I25.89; I42.0; I42.2; I42.5; I42.8;I42.9;I44.0;I44.1;I44.2;I44.30;I45.6;I45.81;I45.859;I47.0;I47.9;I47.10;I47.11;I47.19;I47.20;I48.0;I48.3;I48.4;I48.91;I48.92;I49.8;I49.40;and R00.1;and
- Removed diagnosis code I48.8 from procedure codes 33254; 33255; 33256; 33257; 33258; and 33259 ; and
- Changed the word 'any' to ' ONE or more '; and
- Removed 'or';and
- Added 'orPulsed Field Ablation (PFA)' to Transcatheter Radiofrequency Ablation, Cryoablation section;and
- Reworded In Maze section statement;and
- Removed difficult to treat drug resistantinHyCASAsection;and
- Updated Professional Statements.