CurrentUnitedHealthcarePolicy CS197OH.D

Catheter Ablation for Atrial Fibrillation (for Ohio Only) – Community Plan Medical Policy

Defines UnitedHealthcare Ohio-specific medical policy for catheter ablation for atrial fibrillation in adults (>=18 years), referencing InterQual CP: Procedures, Electrophysiology Testing +/- Catheter Ablation, Cardiac for medical necessity criteria and Ohio Administrative Code for adjudication. Excludes members < 18 years and arrhythmias other than atrial fibrillation.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation for Atrial Fibrillation (for Ohio Only) – Community Plan Medical Policy

Policy CodePolicy CS197OH.D

Change TypeRevised/Added languagearchived prior version

Effective DateMarch 1, 2026

Next Review Date

Key ActionMaintain and provide upon request legible documentation including relevant medical history, physical exam, and pertinent diagnostic test/procedure results to support coverage determination.

SourceLink

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 specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required but do not guarantee coverage.

Revised description for CPT code 93656.

Archived previous policy version CS197OH.C.

1State-specific policy (Ohio)

>=18Age requirement (years)

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Coverage Summary

Defines UnitedHealthcare Ohio-specific medical policy for catheter ablation for atrial fibrillation in adults aged >=18 years, referencing InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac as the primary clinical criteria for medical necessity and using Ohio Administrative Code for adjudication when applicable. The policy excludes members <18 years and arrhythmias other than atrial fibrillation. Coverage stance is mixed (proven and medically necessary in certain circumstances). The FDA classifies ablation catheters for atrial fibrillation as Class III devices requiring premarket approval (PMA).

Medical Necessity Criteria

General Coverage Statement

Covered when ALL of the following are met:

Age requirement: Member is age >= 18 years
Policy does not apply to members aged < 18 years
Arrhythmia type: Arrhythmia is atrial fibrillation
Policy does not apply to arrhythmias other than atrial fibrillation
Clinical criteria source: Medical necessity determined by InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac
Refer to InterQual criteria linked in policy
State OAC adjudication: If service is stated as unproven or has coverage/quantity limit, evaluate using Ohio Administrative Code 5160-1-01 for medical necessity
State requirements govern when conflicts exist

Documentation Requirements for Coverage Review

Documentation that MUST be present in the medical record to support medical necessity:

Documentation Requirements

Medical history: Relevant medical history
Physical examination
Diagnostic tests: Results of pertinent diagnostic tests or procedures
Legibility and availability: Documentation must be legible, maintained in the patient's medical record, and made available upon request

Coding

Referenced 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).

Billing Rule

Do not report CPT 93653 in conjunction with 93656

Per AMA coding guidelines (2024), CPT code 93653 should not be reported in conjunction with 93656.

93653
93656

Provider Actions

Documentation Required

Support medical necessity with complete medical record

Maintain and provide upon request legible documentation that fully supports medical necessity. At a minimum include the relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records must be maintained in the patient’s medical record and made available upon request.

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

Prior Authorization

Adjudicate per InterQual criteria and state OAC when applicable

Determine medical necessity using InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac. If the service is stated as unproven or has a coverage or quantity limit, also evaluate medical necessity under Ohio Administrative Code 5160-1-01.

Background

Catheter ablation for atrial fibrillation is considered proven and medically necessary in certain circumstances. UnitedHealthcare uses InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac as the primary medical/surgical criteria for determining medical necessity. The FDA classifies ablation catheters using any energy type for treatment of atrial fibrillation as Class III devices; premarket approval (PMA) is required.

InterQual is a proprietary clinical criteria set used by UnitedHealthcare to determine medical necessity for procedures including electrophysiology testing and catheter ablation.

Revision History

03/01/2026revisedLatest

03/01/2026addedLatest

Added documentation language stating benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess criteria but do not guarantee coverage; and documentation must include relevant history, physical exam, and pertinent diagnostic test results, be legible, maintained in the record, and made available upon request.