Cardiac Ablation Procedures

Effective Date: October 01, 2019
Revised Date: August 02, 2019
Last Reviewed: September 26, 2019

Description

Catheter ablation is a therapeutic technique using a tripolar electrode catheter or a cryoballoon to eliminate conduction defects.

Maze or Modified Maze Procedures, 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

Cathether Ablation Procedures

  • Intracardiac catheter ablation of atrioventricular node (AV) function may be considered medically necessary for ANY of the following indications:
    • 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; or
    • Atrial tachycardia or atrial flutter; or
    • Atrial ablation for elimination of atrial fibrillation.
  • Comprehensive electrphysiologic evaluation including insertion and repositioning of multiple electrode catheters for treatment of supraventricular tachycardia may be considered medically necessary for ANY of the following indications:
    • Paroxysmal supraventricular tachycardia; or
    • Supraventricular tachycardia; or
    • Accessory bypass tract arrhythmia (Wolff-Parkinson-White Syndrome); or
    • Symptomatic sustained atrioventriuclar nodal reentrant tachycardia; or
    • Atrial tachycardia or atrial flutter; or
    • Atrial ablation for elimination of atrial fibrillation.
  • Comprehensive electrophysiological evaluation, including insertion and repositioning of multiple electrode catheters, for treatment of ventricular tachycardia may be considered medically necessary for ANY of the following indications:
    • Individuals without structrual heart disease (i.e., ischemic or idiopathic cardiomyopathy) with symptomatic sustained monomorphic ventricular tachycardia; or bundle branch reentrant ventricular tachycardia; or
    • Ischemic or idiopathic cardiomyopathy with ventricular tachycardia.

A catheter ablation procedure for all other indications is considered not medically necessary.

Procedure Codes

93650 93653 93654 93655 93657

Transcatheter radiofrequency ablation or cryoablation may be considered medically necessary for ANY of the following indications:

  • As an initial treatment for individuals with symptomatic paroxysmal atrial fibrillation in whom a rhythm-control strategy is desired; or
  • To treat atrial fibrillation for EITHER of the following indications when the individual fails to respond to adequate trials of anti-arrhythmic medications:
    • Symptomatic paroxysmal or symptomatic persistent atrial fibrillation; or
    • As an alternative to atrioventricular nodal ablation and pacemaker insertion in patients with Class II or III congestive heart failure and symptomatic atrial fibrillation.

NOTE: Transcatheter treatment of atrial fibrillation may include pulmonary vein isolation and/or focal ablation.

Repeat transcatheter radiofrequency ablation or cryoablation may be considered medically necessary:

  • In individuals with recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure.

Transcatheter radiofrequency ablation or cryoablation for indications other than listed in this policy are considered experimental/investigational and therefore non-covered. The published data does not support the use of these procedures for any other conditions.

Procedure Codes

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 for all other indications is considered not medically necessary.

Procedure Codes

33250 33251 33261

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 symptomatic, drug-resistant atrial fibrillation or flutter who are undergoing cardiac surgery for non-atrial fibrillation/atrial flutter indication (e.g., valvular surgery).

Maze or modified Maze procedures performed on a non‒beating heart during cardiopulmonary bypass without concomitant cardiac surgery is considered not medically necessary for treatment of symptomatic, drug-resistant atrial fibrillation or flutter.

Maze procedures or modified Maze procedures for all other indications is considered not medically necessary.

Procedure Codes

33256 33257 33259

 

Hybrid catheter and surgical ablation (HyCASA) procedures may be considered medically necessary when ALL of the following criteria are met:

  • The surgeon and electrophysiologist both agree that the individual would be an appropriate candidate for the procedure; and 
  • The individual has persistent difficult-to-treat drug resistant atrial fibrillation greater than  six (6) months; and 
  • One (1) of the following:
    • Previous failed pulmonary vein isolation (PVI); or 
    • Inability to proceed with a standard PVI from an endocardial approach (i.e,. esophageal heating); and 
  • There is a presence of structural heart disease (e.g., left atrial enlargement and/or left ventricular dysfunction); and
  • 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.

Hybrid catheter and surgical ablation (HyCASA) procedures for all other indications is considered not medically necessary.

Procedure Codes

33265 33266 93613 93655 93656 93657 93662

Minimally invasive, off-pump maze and modified maze procedures are considered experimental/investigational and therefore non-covered for treatment of atrial fibrillation or flutter because there is insufficient evidence of their effectiveness.

Procedure Codes

33254 33255 33258

Outpatient HCPCS (C Codes)

C1730 C1731 C1732 C1733 C1759 C1766 C1887
C1892 C1893 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

Covered Diagnosis Codes for Procedure Code 93650

I45.89  I47.1    I47.9  I48.0  I48.11 I48.19  I48.20
I48.21  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 I49.1 I49.3 I49.40
I49.49

Covered Diagnosis Codes for Procedure Code 93655

I48.11 I48.19 I48.20  I48.21  I49.01 I49.02 I49.1
I49.2 I49.3 I49.49  I49.9

Covered Diagnosis Codes for Procedure Codes 93656 and 93657

I25.5 I45.6  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 I49.49 I49.9

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

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

I44.0  I44.1 I44.2  I44.30

Covered Diagnosis Codes for Procedure Codes 33256, 33257, 33259

I48.0 I48.11 I48.19 I48.20 I48.21 I48.3 I48.4
I48.91 I48.92

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



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