CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria: Electrophysiologic (EP) Studies and Intracardiac Catheter Ablations

Clinical review criteria governing medical necessity determinations, authorization requirements, and coding for electrophysiologic studies and intracardiac catheter ablation procedures for Kaiser Foundation Health Plan of Washington members and their providers.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria: Electrophysiologic (EP) Studies and Intracardiac Catheter Ablations

Policy CodePolicy N/A

Change TypeMaterial revisionsMCG guideline adoption and AFib step therapy update

Effective DateSee guideline adoption dates (10/01/2025; updated 09/01/2026)

Next Review DateSep 1, 2026

Key ActionObtain prior authorization and submit the last 6 months of clinical notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

MPC approved revisions to AFib ablation guidelines to allow ablation without strict medication failure requirements; evaluation of risk factors is recommended but no longer mandatory.

Kaiser Permanente will adopt the MCG Electrophysiologic Study and Intracardiac Catheter Ablation guideline for medical necessity determinations effective 10/01/2025 through 09/01/2026 (then updated MCG guideline effective 09/01/2026).

≥1MCG guideline used for medical necessity

93619-93656Primary CPT codes catalogued

09/01/2026Next guideline update

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Coverage and Medical Necessity Criteria

Medically necessary EPS and catheter ablation

Considered medically necessary when criteria in the applicable policy statements and the adopted MCG Electrophysiologic Study and Intracardiac Catheter Ablation guideline are met.

Primary requirement: Procedure meets criteria specified in the applicable policy statements and the adopted MCG Electrophysiologic Study and Intracardiac Catheter Ablation guideline

Providers must follow the MCG guideline used by Kaiser Permanente for detailed indications and contraindications.

Codes listed in this policy are intended to represent commonly used CPT/HCPCS codes for cardiac electrophysiologic studies and intracardiac catheter ablation, but the list is not all-inclusive. Deleted codes and codes not in effect at the time of service may not be covered. To confirm whether a specific code requires prior authorization for a given plan, use the Pre-authorization Code Check referenced in the coding section.

These Clinical Review Criteria are tools to assist in administering plan benefits and do not guarantee coverage. Kaiser Permanente reserves the right to modify or revoke the criteria, and member contracts differ; always consult the member's Evidence of Coverage or contact Kaiser Permanente Member Services to determine coverage for a specific service.

Relevant CPT Codes and Guideline Adoption Dates

Cardiac Electrophysiological (EPS) CPT CodesCPTCovered

93619	Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia.
93620	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording.
93621	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure).
93622	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure).

Cardiac Catheter Ablation CPT CodesCPTCovered

93650	Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement.
93653	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry.
93654	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed.
93655	Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure).
93656	Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and His bundle recording, when performed.

MCG guideline adoption dates and identifiers

Adopted MCG guideline identifierMCG KP-M-154

Initial effective date for adoption10/01/2025

Updated guideline effective date09/01/2026

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Medical necessity will be determined using the adopted MCG guideline.

Step Therapy

AFib Ablation Step-Therapy Update

For requests for catheter ablation (including AFib ablation), do not require documentation of strict medication-failure prior to authorization. Evaluation of patient risk factors (e.g., symptom burden, duration of AF, comorbidities, stroke risk, bleeding risk, and left atrial size) is recommended to support decision-making but is not mandatory.

Denial Risk

Documentation Requirement and Denial Risk

Submit supporting clinical documentation to demonstrate that the requested service meets coverage criteria. Failure to provide required documentation may result in denial of medical necessity.

Clinical Background

An electrophysiologic study (EPS) is a diagnostic, catheter-based procedure that uses intracardiac electrode catheters to record and pace the heart, provoke or induce arrhythmias when indicated, and localize the source or mechanism of abnormal electrical activity. EPS helps determine the effectiveness of antiarrhythmic medications and guides decisions about device implantation or catheter ablation. Intracardiac catheter ablation is a minimally invasive therapy performed during or after EPS that destroys arrhythmogenic tissue using radiofrequency (heat) or cryothermal (cold) energy to restore normal rhythm. These procedures are performed to diagnose and treat clinically significant arrhythmias when supported by the applicable policy criteria and adopted MCG guideline.

Key Definitions

Electrophysiologic Study (EPS) — definition

DefinitionA diagnostic test used to evaluate the electrical activity of the heart and identify abnormal heart rhythms (arrhythmias).

MethodCatheters with electrodes are inserted into the heart through blood vessels; electrodes send signals and measure electrical activity to pinpoint arrhythmia sources.

Clinical usesHelps determine medication effectiveness, need for pacemaker or ICD, and whether catheter ablation is necessary.

Intracardiac catheter ablation — definition

DefinitionA minimally invasive procedure used to treat arrhythmias by destroying the heart tissue causing abnormal electrical signals.

TechniqueCatheters are inserted into the heart through blood vessels and energy (radiofrequency heat or cryoablation cold) is applied to create tiny scars that block faulty signals.

Policy Revisions and Material Changes

2026-09-01material_changeLatest

MPC approved revisions to AFib ablation guidelines to allow ablation without strict medication-failure requirements; evaluation of risk factors is recommended but not mandatory (60-day notice).

2025-10-01adoption

MPC approved adoption of the MCG Electrophysiologic Study and Intracardiac Catheter Ablation guideline for medical necessity determinations (60-day notice).