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

Maze or Modified Maze Procedures, AKA surgical ablation are performed on a non-beating heart during 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.

Catheter 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 electrophysiologic 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 atrioventricular nodal reentrant tachycardia; or
  • Atrial tachycardia or atrial flutter; or
  • Atrial ablation for elimination of atrial fibrillation. 
• Comprehensive electrophysiologic 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 structural 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.

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 antiarrhythmic 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.

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.

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

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

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.

Catheter and transcatheter ablation procedures are typically outpatient procedures which are only eligible for coverage as inpatient procedures in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Operative ablation procedures, including Maze procedures are considered inpatient procedures.