ModifiedBlue Cross Blue Shield - NebraskaPolicy M.31

MA Electrophysiology and Cardiac Ablation (Preauthorization Required)

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Policy governing preauthorization, coverage criteria, and coding for electrophysiology (EP) studies and catheter ablation procedures for supraventricular and ventricular arrhythmias for Blue Cross Blue Shield - Nebraska members.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Electrophysiology and Cardiac Ablation (Preauthorization Required)

Policy CodePolicy M.31

Change TypeMaterial — added allowance to use MCG when NCD insufficient

Effective DateMar 1, 2026

Last ReviewJun 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit procedure and diagnosis code pairs for preauthorization review using the policy's Quick Code Search feature.

SourceLink

POLICY UPDATE CHANGES

MCG may be utilized in this policy when NCD is not sufficient effective 06/01/2026

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ModifiedBlue Cross Blue Shield - NebraskaPolicy M.31

MA Electrophysiology and Cardiac Ablation (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.31 alerts

Get alerted when Policy M.31 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Electrophysiology and Cardiac Ablation (Preauthorization Required)

Policy CodePolicy M.31

Change TypeMaterial — added allowance to use MCG when NCD insufficient

Effective DateMar 1, 2026

Last ReviewJun 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit procedure and diagnosis code pairs for preauthorization review using the policy's Quick Code Search feature.

SourceLink

POLICY UPDATE CHANGES

MCG may be utilized in this policy when NCD is not sufficient effective 06/01/2026

procedure codes enumerated in policy

presentNCD references

multipleGuideline citations

06/01/2026MCG effective

Coverage Criteria

Preauthorization review requires submission of both a valid procedure code and a corresponding diagnosis code. Use the policy’s Quick Code Search to enter the procedure code, then the diagnosis code, and add the code pair to determine whether the combination will be approved, denied, or held for review. A procedure-and-diagnosis pair that is not listed in the policy or does not meet the policy criteria may be denied or held for review.

These Medical Policies are developed by the BCBSN Medical Policy Committee to inform benefit administration but do not themselves constitute authorization, certification, or a contract for benefits. Determinations about benefits for a particular service or item are made according to the terms and conditions of the member’s applicable benefit contract.

Coding

Covered CPT Codes (listed in policy)CPTCovered

93600	BUNDLE OF HIS RECORDING
93602	INTRA-ATRIAL RECORDING
93603	RIGHT VENTRICULAR RECORDING
93609	INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION
93610	INTRA-ATRIAL PACING
93612	INTRAVENTRICULAR PACING
93613	INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING
93618	INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING
93619	COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITHOUT ARRHYTHMIA INDUCTION
93620	COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INDUCTION OR ATTEMPTED INDUCTION

1–10 of 15

1/2

CPT referencesCPT

No codes listed

Provider Actions and Requirements

Prior Authorization

Preauthorization required for listed EP and ablation codes

Preauthorization is required for the electrophysiology (EP) and catheter ablation procedure codes listed in this policy. Providers must submit the procedure and diagnosis code pair for review using the policy’s Quick Code Search feature.

Covered CPT codes include: 93600, 93602, 93603, 93609, 93610, 93612, 93613, 93618, 93619, 93620, 93624, 93650, 93653, 93654, 93656.
Use Quick Code Search: enter procedure code then diagnosis code and click “Add Code Pair” to determine approval, denial, or hold-for-review.

Prior Authorization

Preauthorization required

Preauthorization is required for electrophysiology and cardiac ablation services per this Medical Policy; benefit coverage is determined by the applicable benefit contract and Medical Policy Committee guidance.

Background

Catheter ablation is an established therapeutic option for selected supraventricular and ventricular arrhythmias. The procedure is performed during an electrophysiology study and uses imaging and electro-anatomic mapping to identify arrhythmogenic sites for targeted energy delivery (e.g., radiofrequency or cryothermal) to eliminate or isolate abnormal conduction pathways. Clinical guidance emphasizes optimization of risk factors and guideline-directed medical therapy, stroke prevention where appropriate, and consideration of ablation as first-line therapy in select patients, including some with heart failure.

Definitions and Frameworks

Catheter ablation — Definition

TermCatheter ablation

DefinitionProcedure using radiofrequency or cryothermal energy during an electrophysiology study (EPS) to eliminate arrhythmogenic sites identified by imaging and electro‑anatomic mapping.

PurposeTargets and removes the source of arrhythmia to reduce or prevent recurrent supraventricular and ventricular arrhythmias.

Context of usePerformed after detailed imaging and electro‑anatomic mapping during an EPS to pinpoint abnormal electrical foci.

AF‑CARE framework — Key elements

Framework nameAF‑CARE framework

Revision History

2026-05-14policy_revisionLatest

Added operational allowance to utilize Milliman/MCG criteria when National Coverage Determination (NCD) is not sufficient, with MCG use effective 2026-06-01.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Electrophysiology and Cardiac Ablation (Preauthorization Required)

Policy CodePolicy M.31

Change TypeMaterial — added allowance to use MCG when NCD insufficient

Effective DateMar 1, 2026

Last ReviewJun 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit procedure and diagnosis code pairs for preauthorization review using the policy's Quick Code Search feature.

SourceLink

On This Page

Use Milliman/MCG when NCD is not sufficient (effective 06/01/2026)

When National Coverage Determination (NCD) guidance is not sufficient, Milliman/MCG clinical criteria may be utilized to inform coverage decisions effective 06/01/2026.

If you do not have MCG login credentials or are requesting coverage criteria, contact umanagement@p3hp.org.
MCG access link is provided in the policy for review of criteria.

Step Therapy

Clinical optimization and guideline-directed therapy required prior to procedures

Before pursuing procedural therapy, ensure optimization of risk factors and guideline-directed medical therapy (eg, lifestyle modification, rate/rhythm control, anticoagulation) as described in the clinical rationale and AF-CARE framework.

Address hypertension, diabetes, obesity, sleep apnea, alcohol use, and other comorbidities first.
Document attempts at medical management and shared decision-making prior to ablation when clinically appropriate.

Documentation Required

Provide full code pairs and supporting documentation at time of request

Submit complete procedure and diagnosis code pairs and all requested clinical documentation during the prior authorization process; incomplete documentation may delay review.

Use Quick Code Search to confirm whether a code pair is listed.
If MCG criteria are used, be prepared to provide supporting clinical records or request coverage criteria via umanagement@p3hp.org.

Documentation Required

Provide supporting clinical documentation when MCG criteria are used

When Milliman/MCG criteria are applied for review, providers may be asked to supply supporting clinical documentation or to request the specific coverage criteria via the contact provided (umanagement@p3hp.org).

MCG will be utilized when needed; contact umanagement@p3hp.org for coverage criteria or if you lack login credentials.

Note

Adhere to Medical Policy Committee guidance and referenced CPT codes

Follow the Medical Policy Committee guidance and reference the CPT codes cited in the policy when submitting prior authorization requests; the policy and referenced CPT codes guide benefit determinations.

Use the policy’s listed CPT codes when preparing authorization requests.
Medical Policy Committee determinations inform scientific validity and benefit administration.

Denial Risk

Quick Code Search: missing or non‑conforming code pairs may be denied or held for review

Procedure and diagnosis code pairs that are not included in the policy or do not meet policy criteria may be denied or held for review via the Quick Code Search utility.

Enter the procedure code, then diagnosis code into Quick Code Search; absence from the policy or failure to meet criteria can trigger denial or hold for review.
Ensure code pairs match policy-listed combinations to avoid denials.

Note

Medical Policies do not guarantee authorization or benefits

These Medical Policies are used to administer plan benefits and do not constitute authorization, certification, or a contract for benefits; coverage for a particular service is determined by the terms and conditions of the applicable benefit contract.

Comorbidity and risk‑factor management; Avoid stroke and thromboembolism; Rate and rhythm control; Evaluation and dynamic reassessment.

Clinical emphasisPatient‑centered care with education, shared decision‑making, and multidisciplinary collaboration.

Implementation noteRecommendations structured for intervention, target population, expected benefit, and exceptions; integrates guideline evidence (e.g., STEEER‑AF).

Clinical guideline citations informing policy

Primary AF guideline2023/2024 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation (Circulation 2024).

ESC AF guidelineVan Gelder et al., 2024 ESC Guidelines for the management of atrial fibrillation (Eur Heart J 2024).

Ventricular arrhythmia guidelineZeppenfeld et al., 2022 ESC Guidelines for management of ventricular arrhythmias and prevention of sudden cardiac death (Eur Heart J 2022).

Ventricular arrhythmia / SCDAl‑Khatib et al., 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (Circulation 2018).