CurrentKaiser PermanentePolicy N/A

Electrophysiologic Studies and Intracardiac Ablations - Clinical Review Criteria

Clinical review criteria governing medical necessity determinations for electrophysiologic studies (EPS) and intracardiac catheter ablation for members of Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

Policy Summary

PayerKaiser Permanente

PolicyElectrophysiologic Studies and Intracardiac Ablations - Clinical Review Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for the listed EP study and catheter ablation codes when medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/01/2025policy effective date

05/06/2025last review date

>15references

Yescoding included

Coverage and Medical Necessity Criteria

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These Clinical Review Criteria apply only to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.. They govern medical necessity determinations for electrophysiologic studies (EPS) and intracardiac catheter ablation for members of these plans. Coverage is provided when the criteria in the applicable policy statements are met, including Kaiser Permanente's adoption of the MCG Electrophysiologic Study and Intracardiac Catheter Ablation guideline (KP-M-154) and review for Elective Surgical Procedures as described in the policy. These criteria do not apply to members or services outside the specified Kaiser Foundation Health Plan of Washington products; always verify member-specific benefits and preauthorization requirements prior to ordering services.

CPT / HCPCS Coding for EP Studies and Ablation

Cardiac Electrophysiological (EP) StudiesCPTCovered

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 an 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 AblationCPTCovered

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; 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; 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.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for the listed EP study and intracardiac ablation CPT/HCPCS codes when medical necessity criteria are met per the Electrophysiologic Study and Intracardiac Catheter Ablation (KP-M-154 10012025) MCG Care Guideline and applicable policy statements.

Use the Pre-authorization Code Check to verify authorization requirements by plan type.
Call Kaiser Permanente Clinical Review staff at 1-800-289-1363 to request a copy of the specific MCG criteria used for an individual utilization management decision.

Note

Provider Actions and Operational Notes

Provider actions — initial steps and operational guidance for requesting services and authorizations.

Submit a prior authorization request before scheduling elective EP studies or intracardiac ablations when the procedure is subject to authorization per the member’s plan.
Verify the member’s plan-specific authorization requirements and any network or facility restrictions prior to referral or scheduling.
If the member’s case is urgent/emergent, indicate urgency on the authorization request and follow any expedited review processes required by the plan.

Documentation Required

Required Clinical Documentation

Documentation Requirements: To support medical necessity determinations, submit the following with the authorization request.

Last 6 months of clinical notes from the requesting provider and/or specialist (must be included).
Relevant diagnostic test results and reports (e.g., ECG, Holter, event monitor, echocardiogram, prior EP study reports, imaging) when applicable.
History of symptoms, prior treatments, response to therapies, and rationale for the requested procedure.
For repeat or staged procedures, documentation of prior procedure details and outcomes.
Incomplete or missing documentation (for example, absence of the last 6 months of clinical notes) may result in delays, requests for additional information, or denial of the authorization request.

Clinical Background

An electrophysiologic study (EPS) is a diagnostic procedure in which intracardiac electrode catheters are inserted into the heart to record electrical activity, perform pacing, and attempt to induce or assess arrhythmias. EPS is used to identify the source and mechanism of abnormal cardiac electrical signals and to guide management decisions such as medication adjustments, indications for pacemaker or implantable cardioverter-defibrillator (ICD) therapy, or the need for catheter ablation.

An intracardiac catheter ablation is a minimally invasive therapeutic procedure in which thermal or cryoenergy is delivered via catheter to destroy arrhythmogenic cardiac tissue identified by EPS. Ablation is typically considered when antiarrhythmic medications are ineffective or not tolerated, or when EPS identifies a discrete target amenable to catheter-based treatment.

Key Definitions

EPS (Electrophysiologic Study)

DefinitionElectrophysiologic Study (EPS): a diagnostic test in which catheters with electrodes are inserted into the heart through blood vessels to send electrical signals and measure cardiac electrical activity and to induce or assess arrhythmias.

PurposeIdentifies abnormal heart rhythms (arrhythmias) and pinpoints their source to guide treatment decisions such as medication adjustment, pacemaker/ICD placement, or catheter ablation.

Procedure elementsUses intracardiac electrode catheters inserted via blood vessels to record electrical signals and assess conduction pathways and inducibility of arrhythmia.

Clinical utilityHelps determine effectiveness of antiarrhythmic medications and the need for further interventions including ablation or device therapy.

Catheter ablation (Intracardiac)

DefinitionIntracardiac Catheter Ablation: a minimally invasive procedure in which catheters are advanced into the heart through blood vessels and targeted heart tissue is destroyed using heat (radiofrequency) or cold (cryoablation) energy.

MechanismCreates scars in arrhythmogenic heart tissue to block faulty electrical signals and restore normal rhythm.

Indication contextTypically performed when medications are ineffective or cause significant side effects and when EPS or clinical evaluation localizes an ablatable focus.

ApproachCatheters deliver thermal (radiofrequency) or cryoenergy to create controlled lesions at the site of abnormal conduction.