CurrentUniversity Health Alliance (HSA)Policy MPP-0109-140901
Cardiac Ablation Procedures — Reimbursement and Prior Authorization
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Defines UHA reimbursement, prior authorization, and medical necessity criteria for surgical and catheter cardiac ablation procedures for various arrhythmias; applies to University Health Alliance members and providers seeking payment.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyCardiac Ablation Procedures — Reimbursement and Prior Authorization
Policy CodePolicy MPP-0109-140901
Change TypeNo material change
Effective DateAug 1, 2022
Last ReviewAug 1, 2022
Next Review Date
Key ActionPrior authorization is required for all cardiac catheter ablation procedures and must be requested via the UHA online portal or by phone.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Prior authorization requiredauthorization requirement
~20 codesexample billing codes listed
Covered when medically necessarycoverage stance
Reserved for open heart surgeryMaze procedure restriction
Coverage Criteria for Cardiac Ablation
Main coverage criteria by arrhythmia
Covered when medically necessary and prior authorized; organized by arrhythmia type with condition-specific inclusion and exclusion criteria.
ALL of the following
A. Atrial tachyarrhythmias
- Resuscitated from sudden cardiac death due to atrial flutter or atrial fibrillation with rapid ventricular response in the absence of an accessory pathway.
- Member has a dual-chamber pacemaker with pacemaker-mediated tachycardia that cannot be treated effectively by drugs or by re-programming the pacemaker.
- Symptomatic atrial tachyarrhythmia when pharmacotherapy is not tolerated or the member does not wish to use it, even when ventricular rate can be controlled.
- Symptomatic atrial tachyarrhythmia with inadequately controlled ventricular rates despite therapy.
- Symptomatic non-paroxysmal junctional tachycardia that is drug-resistant, the member is drug-intolerant, or the member declines drug therapy after comprehensive counseling regarding risks and benefits.
B. Atrioventricular nodal reentrant tachycardia (AVNRT)
- Sustained AVNRT identified during electrophysiological study or during catheter ablation of another arrhythmia.
- Symptomatic sustained AVNRT that is drug-resistant, the member is drug-intolerant, or the member does not desire long-term drug therapy after comprehensive counseling.
- Finding of dual AV nodal pathway physiology and atrial echoes without AVNRT on EP study in members clinically suspected of having AVNRT.
C. Atrial tachycardia, flutter, and fibrillation
- Atrial fibrillation, atrial flutter, or atrial tachycardia with evidence of a localized site(s) of origin when the tachycardia is drug-resistant, the member is drug-intolerant, or the member declines long-term drug therapy after comprehensive counseling.
- As an alternative to atrioventricular nodal ablation and pacemaker insertion in patients with class II or III congestive heart failure and symptomatic atrial fibrillation.
- Transcatheter radiofrequency ablation or cryoablation as initial treatment for recurrent symptomatic paroxysmal atrial fibrillation (>1 episode, with 4 or fewer episodes in the previous 6 months) when a rhythm-control strategy is desired.
- Repeat radiofrequency or cryoablation is covered for recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure.
- Maze procedure performed with cardiopulmonary bypass on a beating heart is medically necessary when: (1) patient did not respond to other medical treatments or those treatments were contraindicated; or (2) patient cannot tolerate side effects of drug therapy (adequate documentation required); or (3) patient is suffering hemodynamic consequences of chronic atrial fibrillation despite adequate medical management; or (4) patient is at high risk for thromboembolism (prior thromboembolism with other sources ruled out, or documented long‑standing AF with mitral valve disease undergoing open surgical repair).
- Because of invasiveness, Maze is generally reserved for patients undergoing open heart surgery for other reasons; minimally invasive/off‑pump Maze (thoracoscopic off‑pump surgical ablation/TOPS) is not considered medically necessary.
Operational limitation
D. Accessory pathways (including WPW)
- Asymptomatic members with ventricular pre-excitation when livelihood, profession, important activities, insurability, mental well-being, or public safety would be affected by spontaneous tachyarrhythmias or the ECG abnormality.
- Members with a family history of sudden cardiac death.
- Atrial fibrillation (or other atrial tachyarrhythmias) with a rapid ventricular response via the accessory pathway when the tachycardia is drug-resistant, the member is drug-intolerant, or the member declines long-term drug therapy after comprehensive counseling.
- Atrial fibrillation with a controlled ventricular response via the accessory pathway.
- AV reentrant tachycardia or atrial fibrillation with rapid ventricular rates identified during electrophysiological study of another arrhythmia.
- Symptomatic AV reentrant tachycardia that is drug-resistant, the member is drug-intolerant, or the member does not desire long-term drug therapy after comprehensive counseling.
E. Ventricular tachycardia (VT)
- Bundle branch reentrant ventricular tachycardia.
- Sustained monomorphic VT in members with an implantable cardioverter-defibrillator (ICD) receiving multiple shocks not manageable by reprogramming or concomitant drug therapy.
- Symptomatic sustained monomorphic VT when the tachycardia is drug-resistant, the member is drug-intolerant, or the member declines long-term drug therapy after comprehensive counseling.
- Symptomatic non-sustained VT when drug-resistant, drug-intolerant, or the member declines long-term drug therapy after comprehensive counseling.
Operator and setting requirements
- Surgical and catheter ablation are covered only when performed by an electrophysiologist with appropriate training in an experienced center.
- Procedure includes temporary pacemaker placement if indicated.
Exclusions (Experimental/Investigational)
- Cardiac catheter ablation is considered experimental and investigational for indications not listed, including: benign non-sustained VT that does not cause symptoms; hypertrophic cardiomyopathy; multifocal atrial tachycardia (MAT); other uses of radiofrequency catheter ablation not indicated above (e.g., AV junction ablation with pacemaker implantation for symptomatic drug‑refractory AF); and unstable, rapid, multiple, or polymorphic VT that cannot be adequately localized by mapping techniques.
Billing and Coding
Example codes referencedCPT | HCPCS | mixed
| 33250 | Operative ablation of supraventricular arrhythmogenic focus or pathway (e.g., Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); without cardiopulmonary bypass. |
| 33251 | Operative ablation of supraventricular arrhythmogenic focus or pathway (e.g., Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); with cardiopulmonary bypass. |
| 33254 | Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure). |
| 33255 | Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); without cardiopulmonary bypass. |
| 33256 | Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); with cardiopulmonary bypass. |
| 33257 | Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (e.g., modified maze procedure). |
| 33258 | Operative tissue ablation and reconstruction of atria performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), without cardiopulmonary bypass. |
| 33259 | Operative tissue ablation and reconstruction of atria performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), with cardiopulmonary bypass. |
| 33261 | Operative ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass. |
| 33265 | Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass. |
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Recurrent symptomatic paroxysmal AF episodes — criterion detail about episode counts and timeframe for initial treatment
Initial treatment episode threshold>1 episode with 4 or fewer episodes in the previous 6 months (transcatheter RF or cryoablation for recurrent symptomatic paroxysmal AF when rhythm-control is desired)
Repeat procedureRepeat radiofrequency or cryoablation is covered for recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure
Context for useCovered as an initial treatment when a rhythm-control strategy is desired
Provider Actions, Authorization and Documentation
Prior Authorization
Prior authorization required — how to submit
Prior authorization is required for all cardiac catheter ablative treatments. To request prior authorization, submit via UHA's online portal; if a login has not been established, contact UHA at 808-532-4000 to establish one. Prior authorization determinations will be based on standard clinical criteria (e.g., current Milliman Care Guidelines) and must include documentation that detailed informed consent has been obtained.
- Submit prior authorization requests through UHA's online portal; phone 808-532-4000 only to establish portal login.
- Prior authorization decisions rest on standard clinical criteria and documented detailed informed consent.
Documentation Required
Documentation retention and detailed informed consent
Maintain legible documentation of medical necessity in the patient's medical record and make it available to UHA upon request. Documented informed consent must be detailed and address specified risks, benefits, and comparative information as listed below.
- Retain and produce upon request: documentation supporting medical necessity, kept in the patient's medical record and legible.
- Informed consent must describe: approximate likelihood of long-term success (including operator experience and chances of repeat procedures), significance of radiation exposure, quantitative risk of thromboembolic events with alternative therapies, actual physiologic benefit of restoring electrocardiac function, and risks of the contemplated procedure relative to drug or no therapy.
Definitions and Scope Notes
Prior authorization definition — payer-required pre-approval process for cardiac catheter ablation procedures
DefinitionPrior authorization is a payer-required pre-approval process for cardiac catheter ablation procedures
How to requestRequest prior authorization via the UHA online portal or by contacting UHA (per Administrative Guidelines)
Basis for approvalPrior authorization will be based on standard clinical criteria and documented informed consent (detailed consent addressing risks and alternatives)
Experimental and investigational — list of indications considered experimental/investigational and not covered
Benign non-sustained VTBenign non-sustained ventricular tachycardia that does not cause symptoms is considered experimental/investigational and not covered
Hypertrophic cardiomyopathyCardiac catheter ablation for hypertrophic cardiomyopathy is considered experimental/investigational and not covered
Multifocal atrial tachycardia (MAT)Ablation for multifocal atrial tachycardia is considered experimental/investigational and not covered
Other off‑label RF usesOther uses of radiofrequency catheter ablation not indicated in policy (e.g., AV junction ablation with pacemaker for symptomatic drug-refractory AF) are considered experimental/investigational and not covered
Unstable/rapid/multiform VTUnstable, rapid, multiple, or polymorphic VT that cannot be adequately localized by mapping techniques is considered experimental/investigational and not covered
Operative ablation — statement that surgical (operative) ablation procedures are medically necessary when criteria met
Coverage stanceUHA considers operative (surgical) ablation medically necessary when criteria are met
Use caseOperative ablation may be used to eliminate atrioventricular condition defects and for Maze procedure when specified criteria are met
Provider requirementsSurgical and catheter ablation are covered only when performed by an electrophysiologist with appropriate training in an experienced center
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyCardiac Ablation Procedures — Reimbursement and Prior Authorization
Policy CodePolicy MPP-0109-140901
Change TypeNo material change
Effective DateAug 1, 2022
Last ReviewAug 1, 2022
Next Review Date
Key ActionPrior authorization is required for all cardiac catheter ablation procedures and must be requested via the UHA online portal or by phone.
SourceLink
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