Catheter Ablation for Atrial Fibrillation (for North Carolina Only)
State-specific UnitedHealthcare medical policy governing coverage and coding for catheter ablation to treat atrial fibrillation for members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity per InterQual
Covered when ALL of the following are met:
Policy defers to InterQual for detailed clinical criteria.
This policy does not apply to members under the age of 18 or to arrhythmias other than atrial fibrillation. Coverage determinations and clinical criteria described in this document are specific to adult members with atrial fibrillation and should not be used for pediatric patients or for other arrhythmia diagnoses.
Coding / Billing
| 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). |
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