Currentpriority healthPolicy 91314-R14

Electrophysiology Testing and Catheter Ablation for Cardiac Arrhythmias

Defines Priority Health's coverage positions for electrophysiology (EP) testing and catheter ablation for cardiac arrhythmias, lists exclusions (investigational/experimental), references use of InterQual criteria for medical necessity determinations, and provides coding guidance and regulatory/guideline references.

Policy Summary

Payerpriority health

PolicyElectrophysiology Testing and Catheter Ablation for Cardiac Arrhythmias

Policy CodePolicy 91314-R14

Change TypeAdded exclusion

Effective DateDec 1, 2025

Next Review Date

Key ActionMedical necessity for catheter ablation is determined through InterQual criteria; providers must submit prior authorization requests where required and reference InterQual guidance accessible via Priority Health Prism.

SourceLink

POLICY UPDATE CHANGES

New exclusion: Cardioneural ablation for treatment of vasovagal syncope is considered experimental, investigational or unproven.

3Explicit Exclusions Listed

SeveralCPT/HCPCS Codes Listed

InterQualMed necessity method

Coverage Summary

This policy addresses Priority Health coverage for electrophysiology (EP) testing and catheter ablation for cardiac arrhythmias. EP testing is covered without prior authorization, and medical necessity for catheter ablation is determined using the InterQual® criteria (providers access InterQual via Priority Health Prism). The overall coverage stance is mixed: standard EP testing and many ablation procedures are covered when InterQual criteria are met, while certain technologies and procedures are explicitly excluded as investigational or unproven.

Coding Guidance

Covered / No prior authorization required EP testing & mappingCPTCovered

93613	Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) (no PA required)
93653	Comprehensive electrophysiologic evaluation... with intracardiac catheter ablation of arrhythmogenic focus; treatment of supraventricular tachycardia or other single atrial focus
93654	Comprehensive EP evaluation... with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D
93655	Intracardiac catheter ablation of a discrete mechanism of arrhythmia distinct from the primary ablated mechanism (List separately)
93656	Comprehensive EP evaluation with transseptal catheterizations... intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping
93657	Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately)
33265	Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass (No PA required)
33266	Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure), without cardiopulmonary bypass (No PA required)

Covered HCPCS / SuppliesHCPCS|CPTCovered

C1732	Catheter, Electrophysiology, diagnostic/ablation 3D or vector mapping
C1886	Catheter, extravascular tissue ablation, any modality (insertable)

Not covered / Experimental use reporting codesCPT|HCPCSNot Covered

93799	Unlisted cardiovascular service or procedure (Not covered when used for High-intensity focused ultrasound (HIFU) ablation). Explanatory notes must accompany claim
C1889	Implantable/insertable device, not otherwise classified (Considered Experimental/Investigational/Unproven when used to report use of an active esophageal cooling device during cardiac catheter ablation)

ICD-10 Diagnosis codes that may applyICD-10

I44.30	Atrioventricular block (range I44.30 - I44.7 indicated)
I44.7	Atrioventricular block unspecified
I45.0	Other conduction disorders (I45.0 - I45.9 range indicated)
I45.9	Conduction disorder, unspecified
I47.0	Paroxysmal tachycardia (I47.0 - I47.9 range indicated)
I47.9	Cardiac arrhythmia, unspecified
I48.0	Atrial fibrillation and flutter (I48.0 - I48.92 range indicated)
I48.92	Atrial fibrillation unspecified
I49.0	Other cardiac arrhythmias (I49.0 - I49.9 range indicated)
I97.190	Other postprocedural cardiac functional disturbances following surgery (I97.190 - I97.191 indicated)

1–10 of 11

1/2

Coding and billing notes: specific CPT/HCPCS codes have operational annotations — several mapping/adjunct CPTs are designated to be listed separately in addition to the primary procedure (for example, 93613, 93655, 93657 are list-separately codes), and some CPTs are noted as No PA required (for example, 93613, 33265, 33266). When reporting unlisted cardiovascular procedure code 93799 for technologies such as HIFU ablation, explanatory notes must accompany the claim. Use of HCPCS code C1889 to report an active esophageal cooling device during cardiac catheter ablation is flagged for experimental/investigational reporting and may be denied.

Provider Actions & Billing Rules

Prior Authorization

Catheter ablation prior authorization via InterQual

Medical necessity for catheter ablation is determined using InterQual criteria; providers can access InterQual via Priority Health Prism under Authorizations -> Authorization Criteria Lookup for prior authorization guidance.

Providers access InterQual via Priority Health Prism -> Authorizations -> Authorization Criteria Lookup

Documentation Required

Claims for excluded technologies require explanatory notes

When reporting unlisted cardiovascular procedure code 93799 for HIFU ablation, explanatory notes must accompany the claim; use of HCPCS code C1889 to report an active esophageal cooling device during cardiac catheter ablation is considered experimental and may be denied.

Affected codes: 93799, C1889
Denial risk: 93799 requires explanatory notes and is not covered for HIFU; C1889 for active esophageal cooling is considered experimental/investigational and may be denied

Billing Rule

List separately rules for mapping/adjunct codes

List-separately rules apply for mapping/adjunct codes — codes such as 93613, 93655, 93657, 33265, and 33266 should be reported in addition to the primary procedure when applicable; several (e.g., 93613, 33265, 33266) are indicated as No PA required.

93613
93655
93657
33265
33266
Notes: 93613, 33265, and 33266 are listed as No PA required

Background & Evidence

Background: Atrial fibrillation (AF) is the most commonly diagnosed cardiac rhythm disturbance and is characterized by loss of normal sinoatrial electrical signal with rapid, disorganized atrial contraction; AF is associated with significant morbidity and mortality and limited long-term success with antiarrhythmic drugs. Catheter ablation targets arrhythmogenic foci and can be performed using radiofrequency, cryo, microwave, or ultrasound energy sources. The Cox-maze IV (a minimally invasive epicardial ‘‘mini-maze’’) produces epicardial scar lines to divert abnormal impulses; the Cox-maze III is an open surgical approach often used with valve surgery. The convergent procedure combines a Cox-maze IV with endocardial ablation to create additional interior lesions. Major procedural risks include a small but significant risk of pulmonary vein stenosis after pulmonary vein isolation and the potential for esophageal thermal injury because of the anatomic proximity of the posterior left atrium to the esophagus.

Source	Finding/Note
FDA De Novo
ensoETM® (Haemonetics®) granted De Novo classification DEN230021 (notice date 2023-09-13) as a temperature regulation device intended to reduce the likelihood of ablation‑related esophageal injury during radiofrequency cardiac ablation procedures.
Registry outcomes (Tung et al., 2025)
Multicenter CNA registry (n=205 patients) reported 78% syncope‑free at mean 14 months follow‑up; major adverse event rate 1.4%.
Randomized trial (Piotrowski et al., 2023)
Prospective randomized trial in cardioinhibitory vasovagal syncope (n=48) showed reduced syncope recurrence with CNA (8% vs 54%) over 2 years (P = 0.0004) and improved quality of life.

Definitions

EP testingElectrophysiology testing (diagnostic evaluation of cardiac electrical conduction and arrhythmia induction); EP testing does not require prior authorization.

InterQualA proprietary clinical criteria tool used to determine medical necessity for procedures (medical necessity for catheter ablation determined through InterQual® criteria).

Cardioneural ablation (CNA)Catheter-based procedure targeting ganglionated plexi to modify autonomic inputs to treat vasovagal syncope and functional bradyarrhythmias; considered experimental/investigational/unproven for treatment of vasovagal syncope (excluded).

ensoETM®Active esophageal cooling device intended to reduce ablation-related esophageal injury during radiofrequency cardiac ablation; use during cardiac catheter ablation is considered experimental/investigational/unproven (FDA De Novo DEN230021 noted).

Exclusions & Experimental Technologies

Exclusions and new changes: the policy lists specific investigational/unproven exclusions including high-intensity focused ultrasound (HIFU) as a stand-alone AF ablation modality, and use of an active esophageal cooling device (e.g., ensoETM®) during cardiac catheter ablation is considered experimental, investigational or unproven. The policy has a material change adding an explicit exclusion that cardioneural ablation for treatment of vasovagal syncope is considered experimental, investigational or unproven. Although the FDA granted a De Novo classification for ensoETM® (DEN230021), the policy states there is currently insufficient evidence from large, well-designed randomized trials to support routine use of active esophageal cooling devices; therefore these devices are considered experimental in this coverage policy (see evidence table/registries referenced in the policy).

Revision History

policy_changeLatest

Added exclusion: Cardioneural ablation for treatment of vasovagal syncope is considered experimental, investigational or unproven. This exclusion is explicitly listed in the Exclusions section and reiterated in the Background/evidence discussion.

evidence_reviewLatest

Background/evidence discussion summarizes cardioneural ablation (CNA) technique and cites registry and randomized trial outcomes: a multicenter U.S. CNA registry (n=205) reporting 78% syncope-free at mean 14 months with 1.4% major adverse event rate, and a 48‑patient randomized trial showing reduced syncope recurrence (8% vs 54%) over 2 years.

OpenPayer