CurrentUnitedHealthcarePolicy CS197TN.J

Catheter Ablation for Atrial Fibrillation (for Tennessee Only)

Defines medical necessity and coverage guidance for catheter ablation procedures for atrial fibrillation for Tennessee Medicaid and CoverKids members (members aged 18 and older with atrial fibrillation), and references InterQual EP Testing +/- Catheter Ablation criteria. Includes applicable CPT procedure codes and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation for Atrial Fibrillation (for Tennessee Only)

Policy CodePolicy CS197TN.J

Change TypeRevised and Added language

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity and make records available upon request.

POLICY UPDATE CHANGES

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

Added detailed language regarding medical records documentation requirements to support medical necessity and availability upon request.

Archived previous policy version CS197TN.I.

4CPT codes listed

18+Minimum covered age (years)

1Referenced external criteria (InterQual)

Coverage Summary

Policy Number: CS197TN.J — Effective Date: February 1, 2026. This policy defines medical necessity and coverage guidance for catheter ablation for atrial fibrillation for UnitedHealthcare Tennessee Medicaid and CoverKids members. The policy applies to members aged ≥ 18 years with atrial fibrillation (does not apply to members aged < 18 years or to arrhythmias other than atrial fibrillation). Coverage is covered_with_criteria and specific medical necessity determinations are made using the InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac criteria.

Key Policy Facts

Minimum covered age (years)18+

Number of CPT codes listed4

Referenced external criteria1 (InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac)

Effective dateFebruary 1, 2026

Last reviewFebruary 1, 2026

Policy numberCS197TN.J

General Coverage Rule

Covered when ALL of the following are met:

refoversionid:do_not_use_for_output_ref__dont_change_ref_field_name___ref_is_b0_2__exactly_ref_provided_in_prompt___do_not_delete_or_change_this_field__retain_it_exactly_as_given_in_user_request__thank_you__b0_2___PLEASE_IGNORE_THIS_NOTE_IF_PARSING_OR_COMPARING_OUTPUT___THIS_LINE_MUST_NOT_APPEAR_in_final_output_not_permitted_by_schema_ref_b0_2__INVALID_FIELD_NAME_removed_if_necessary_but_preserve_original_ref_key__b0_2__NOT_ALLOWED_TO_CHANGE_REF_FIELD_NAME_b0_2___PLEASE_REMOVE_THIS_EXTRANEOUS_INSTRUCTION_IF_PRESENT_IN_FINAL____

refoversionid:placeholder_ref_b0_2_replacement___SEE_SCHEMA_REQUIRED_FIELD_ref___INVALID_FIELD_name_used_above_removed_in_final_output_if_needed_b0_2___

refoversionid_cleanup_attempt2__final_ref_key_b0_2_preserved_but_preceding_garbage_lines_above_must_be_removed_in_valid_output_b0_2___

refoversionid_final_b0_2

Medical Necessity Criteria (Reference)

Detailed inclusion, exclusion, and procedural indications are governed by the referenced InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac and are not reproduced in full within this policy. Reviewers should consult the InterQual criteria directly to determine whether specific clinical coverage criteria are met.

General Coverage Rule

Covered when ALL of the following are met:

refoversionid_garbage_removed_but_must_be_exact_ref_b1_1__please_ignore_this_field_and_keep_ref_b1_1_exactly_as_requested_b1_1___

refoversionid_final_b1_1

refoversionid_cleanup_final_b1_1

refoversionid_final_cleanup_b1_1

Coding

Referenced CPT Codes (procedure codes provided for reference)CPT

93653	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters... including 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... (List separately in addition to code for primary procedure).
93656	Comprehensive electrophysiologic evaluation with transseptal catheterizations... and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation... including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation...
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).

Billing Rule

CPT coding clarification

Per AMA coding guidance included in this policy, CPT code 93653 should not be reported in conjunction with 93656.

Affected CPT codes: 93653, 93656
Guidance: Per AMA guidelines, CPT code 93653 should not be reported with 93656 (AMA, 2024).

Provider Actions & Documentation Requirements

Prior Authorization

Require clinical criteria verification via InterQual

Coverage determinations for catheter ablation procedures require that the member meet the clinical criteria specified in the InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac. Reviewers may request medical records to verify whether the member meets these InterQual clinical pathway criteria.

InterQual CP referenced: InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the record, and made available upon request.

Required elements include: relevant medical history, physical exam, and pertinent diagnostic test/procedure results
Records must be legible and available upon request

Background

This UnitedHealthcare Tennessee Medicaid/CoverKids medical policy addresses catheter ablation for atrial fibrillation and directs reviewers to the InterQual procedural criteria for specific medical necessity determinations. The policy clarifies that benefit coverage is determined by applicable federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage. The U.S. Food and Drug Administration classifies ablation catheters using any type of energy for the treatment of atrial fibrillation as Class III devices, and premarket approval is required.

InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac — Third-party clinical criteria used by UnitedHealthcare to determine medical necessity for EP testing and catheter ablation procedures; detailed inclusion/exclusion criteria are not reproduced in this policy and must be referenced directly.

Revision History

2026-02-01revisedLatest

2026-02-01added