CurrentUnitedHealthcarePolicy CS197ID.A

Catheter Ablation for Atrial Fibrillation (for Idaho Only)

Defines UnitedHealthcare coverage principles for catheter ablation to treat atrial fibrillation for members in Idaho, including Idaho Medicaid Plus; does not apply to patients under 18 or to other arrhythmias.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation for Atrial Fibrillation (for Idaho Only)

Policy CodePolicy CS197ID.A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting authorization for listed CPT codes, provide documentation showing the member meets InterQual Electrophysiology criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Idahogeographic scope

18+age applicability

InterQualclinical criteria

4 codesprocedure codes

Coverage Criteria for Catheter Ablation — Atrial Fibrillation

Medical necessity (InterQual-referenced)

Covered when InterQual Electrophysiology (EP) Testing +/Radiofrequency Ablation or Cryothermal Ablation criteria are met.

Adult AF patients: Member is age 18 years or older and has atrial fibrillation (policy excludes ages < 18 and arrhythmias other than AF).age >= 18

Policy explicitly excludes members < 18 and non-AF arrhythmias.

InterQual medical necessity: Member meets the InterQual CP: Procedures, Electrophysiology criteria for catheter ablation (radiofrequency or cryothermal) for atrial fibrillation.per InterQual

InterQual CP: Procedures, Electrophysiology (EP) Testing +/Radiofrequency Ablation or Cryothermal Ablation, Cardiac defines the specific clinical criteria.

This policy does not apply to members younger than 18 years or to arrhythmias other than atrial fibrillation.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation for Atrial Fibrillation (for Idaho Only)

Policy CodePolicy CS197ID.A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting authorization for listed CPT codes, provide documentation showing the member meets InterQual Electrophysiology criteria.

SourceLink

On This Page

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Applicable Procedure Codes

Applicable CPT codesCPT

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, Authorization, and Documentation

Prior Authorization

InterQual-based medical necessity for authorization

Coverage decisions reference InterQual Electrophysiology criteria. Providers should follow plan requirements and may need to supply documentation for review; catheter ablation for atrial fibrillation is considered medically necessary only when the member meets InterQual® CP: Procedures, Electrophysiology criteria. Note: this policy does not apply to members < 18 years or to arrhythmias other than atrial fibrillation.

Prior authorization may be required per plan contract and InterQual review
Provide complete clinical documentation to demonstrate InterQual criteria are met

Documentation Required

Medical records documentation

Providers must submit all requested medical records documentation to support that the member meets the clinical criteria for coverage. Medical records may be required to assess eligibility but do not guarantee coverage.

Include relevant history, diagnostic testing, prior therapies, and procedural notes
Reference the InterQual criteria used for the review

Denial Risk

Documentation-related denial risk

Lack of required medical records or insufficient documentation to demonstrate that the member meets clinical criteria may result in denial of the request. Ensure records are complete and submitted in a timely manner to avoid adverse coverage determinations.

Incomplete records or missing justification for meeting InterQual criteria increases denial risk
Denials follow applicable federal, state, or contractual requirements

Procedure Definitions / Code Descriptions

Definition — CPT 93656

CPT code 93656Comprehensive 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.

Includes proceduresPulmonary vein isolation; 3-dimensional mapping; intracardiac echocardiography (when performed); transseptal catheterizations.

Usage noteListed as a comprehensive procedure for AF ablation (pulmonary vein isolation) and includes associated mapping and imaging when performed.

Definition — CPT 93657

CPT code 93657Additional 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).

When to reportReport 93657 in addition to the primary pulmonary vein isolation procedure when further linear or focal ablation of the left or right atrium is required after completion of PVI.

Relationship to primary codeDesigned to be listed separately in addition to the primary ablation code (e.g., 93656) when additional ablation is performed.

OpenPayer

Catheter Ablation for Atrial Fibrillation (for Idaho Only)

Coverage Criteria for Catheter Ablation — Atrial Fibrillation

Applicable Procedure Codes

Provider Actions, Authorization, and Documentation

Clinical Background

Procedure Definitions / Code Descriptions