CurrentUnitedHealthcarePolicy CS197TN.J

Catheter Ablation Atrial Fibrillation Tn Cs

Defines medical policy for catheter ablation for atrial fibrillation for Tennessee Medicaid and CoverKids members aged 18 and older, referencing InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac for clinical criteria and documenting medical record requirements.

Policy Summary

PayerUnitedHealthcare

PolicyCatheter Ablation Atrial Fibrillation Tn Cs

Policy CodePolicy CS197TN.J

Change TypeRevised referencesadded documentation requirements

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must ensure medical records include relevant medical history, physical exam, and results of pertinent diagnostics to support medical necessity; documentation must be legible, retained in the record, and available upon request.

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 regarding medical records documentation requirements to assess medical necessity.

Archived previous policy version CS197TN.I.

1Referenced External Criteria (InterQual)

4CPT Codes Listed

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Coverage Summary

This policy defines coverage for catheter ablation for atrial fibrillation for Tennessee Medicaid and CoverKids members aged 18 years and older. Coverage determination relies on meeting the InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac clinical criteria and required medical record documentation to support medical necessity.

Coverage stance: covered_with_criteria. Effective/Last review date: February 1, 2026. Policy number: CS197TN.J.

Key facts

Referenced External Criteria (InterQual)1

CPT Codes Listed4

Age restriction (years)18+

Medical policy statusCURRENT

SubjectCatheter ablation for atrial fibrillation (Tennessee Medicaid/CoverKids)

Medical Necessity Criteria (InterQual-referenced)

General coverage statement

Catheter ablation for atrial fibrillation is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac.

General coverage criteria

Age requirement: Member is age >= 18 years
Policy does not apply to members aged < 18 years
Diagnosis requirement: Diagnosis is atrial fibrillation (not other arrhythmias)
Policy does not apply to arrhythmias other than atrial fibrillation
InterQual criteria: Member meets InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac clinical criteria

Coding

Referenced CPT codes (for reference)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).

Evidence and coding guidance: AMA guidance: do not report CPT 93653 in conjunction with 93656.

FDA device classification: ablation catheters for atrial fibrillation are class III devices (product code OAE) and require premarket approval.

Documentation guidance: benefit coverage is determined by federal/state/contractual requirements; medical records documentation may be required to assess clinical criteria and must include relevant medical history, physical exam, and results of pertinent diagnostic tests, be legible, maintained in the patient's medical record, and available upon request.

Provider Actions & Billing Guidance

Documentation Required

Maintain complete medical record documentation

Providers must ensure medical records include relevant medical history, physical exam, and results of pertinent diagnostics to support medical necessity; documentation must be legible, retained in the record, and available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Documentation must be legible and available upon request

Prior Authorization

Use InterQual criteria to determine medical necessity

Coverage determination requires that the member meet InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac clinical criteria; providers should reference InterQual when requesting coverage.

Background & Evidence

This UnitedHealthcare Tennessee Medical Policy covers catheter ablation for atrial fibrillation for Medicaid and CoverKids members. The policy specifies that it does not apply to members aged < 18 years or to arrhythmias other than atrial fibrillation and directs users to InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac for the clinical coverage criteria.

The policy references InterQual clinical criteria for medical necessity and notes that the FDA classifies ablation catheters for atrial fibrillation as class III devices requiring premarket approval.

Evidence Item	Summary
FDA device classification	Ablation catheters for atrial fibrillation are class III devices (product code OAE)
Coding guidance	AMA guidance: do not report CPT 93653 in conjunction with 93656

Definitions: InterQual CP — a third-party clinical criteria tool used to determine medical necessity for procedures (InterQual CP: Procedures, Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac).

Revision History

2026-02-01revisedLatest

2026-02-01addedLatest

Added detailed language that benefit coverage is determined by federal/state/contractual requirements; medical records documentation may be required to assess clinical criteria and does not guarantee coverage; examples of required documentation include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the patient's medical record, and available upon request.