CurrentUnitedHealthcarePolicy CS197NE.J

Catheter Ablation for Atrial Fibrillation (for Nebraska Only)

Defines UnitedHealthcare's medical policy for catheter ablation to treat atrial fibrillation for members in Nebraska age ≥18, referencing InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac for medical necessity criteria and documenting medical record requirements.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation for Atrial Fibrillation (for Nebraska Only)

Policy CodePolicy CS197NE.J

Change TypeRevised references & documentation requirements

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully documents medical necessity including relevant medical history, physical exam, and results of pertinent diagnostic tests/procedures; records must be legible and available upon request.

POLICY UPDATE CHANGES

Replaced reference to InterQual 'EP Testing +/- Radiofrequency Ablation (RFA) or Cryothermal Ablation, Cardiac' with 'InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac'.

Added detailed language specifying that the patient's medical record must fully support medical necessity and listing examples of required documentation (medical history, physical exam, diagnostic test results); removed a prior reference link to 'Medical Records Documentation Used for Reviews'.

NebraskaGeographic scope

≥18Applicable age

InterQualCoverage decision tool

Coverage Summary

This policy (CS197NE.J) defines UnitedHealthcare's medical coverage for catheter ablation to treat atrial fibrillation for members in the State of Nebraska, and applies to members aged ≥ 18. The coverage stance is covered with criteria and medical necessity is determined by reference to the third-party clinical decision tool InterQual ® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac. The policy requires that the patient's medical record fully support medical necessity with documented medical history, physical exam, and results of pertinent diagnostic tests or procedures. The policy also notes the FDA classifies ablation catheters used to treat atrial fibrillation as Class III devices (PMA product code OAE).

Key policy facts

Geographic scopeNebraska-only

Applicable ageAge ≥ 18

Coverage decision toolInterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac

Effective dateFebruary 1, 2026

Last reviewFebruary 1, 2026

Policy numberCS197NE.J

Medical-Necessity Criteria

General Applicability / Exclusions

Policy-level scope and exclusions:

ALL of the following

Applies in Nebraska only: Applies only to members in the State of Nebraska
Age exclusion: Does not apply to members aged < 18 years
Arrhythmia scope: Does not apply to arrhythmias other than atrial fibrillation

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title": "General Applicability / Exclusions

Medical Necessity

Catheter ablation for atrial fibrillation is considered medically necessary when InterQual CP criteria are met:

InterQual CP criterion required: Member meets the InterQual ® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac criteria for catheter ablation of atrial fibrillation

Policy references InterQual for specific inclusion/exclusion and detailed clinical coverage criteria

Documentation Requirements

Medical records documentation required to support medical necessity:

General documentation requirement: Medical record must fully support medical necessity for requested services

Required documentation elements: Documentation must include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures

Documentation must be legible, maintained in the medical record, and made available upon request

Coding

Relevant CPT codes (reference list)CPT

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.
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 with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed.
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 in addition to code for primary procedure).

Provider Actions / Billing Impact

Documentation Required

Support medical necessity with records

The patient's medical record must fully support the medical necessity for the requested services. Documentation must be legible, maintained in the medical record, and made available upon request.

Relevant medical history
Physical examination
Results of pertinent diagnostic tests or procedures

Prior Authorization

Use InterQual criteria to determine coverage

Prior authorization and coverage determinations should reference InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac to establish medical necessity for catheter ablation for atrial fibrillation.

Billing Rule

CPT coding guidance

Per AMA coding guidance (2024), do not report CPT code 93653 in conjunction with 93656.

93653
93656
AMA CPT guidance, 2024

Background

This UnitedHealthcare medical policy governs catheter ablation for atrial fibrillation in the State of Nebraska (Policy Number: CS197NE.J). The policy applies only in Nebraska and does not apply to members aged <18 years or to arrhythmias other than atrial fibrillation.

For specific medical necessity determinations the policy references the InterQual ® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac criteria. The policy instructs reviewers to use those InterQual criteria to establish whether catheter ablation meets medical necessity.

The policy requires that the patient's medical record contain documentation that fully supports the medical necessity for the requested services; required documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the medical record, and made available upon request.

For informational purposes the policy notes the U.S. Food and Drug Administration classifies ablation catheters using any type of energy for treatment of atrial fibrillation as Class III devices and that premarket approval is required (search product code OAE in the FDA PMA database).

InterQual ® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac — third-party clinical criteria referenced by the policy to determine specific medical necessity for catheter ablation procedures.

Revision History

2026-02-01revisedLatest

Removed prior reference link to 'Medical Records Documentation Used for Reviews' and added detailed documentation requirements stating the patient's medical record must fully support medical necessity; documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and must be legible, maintained in the medical record, and made available upon request.