Diagnostic Endocardial Electrical Stimulation (EES)
Separate payment should not be made for the HIS bundle cardiogram or an ECG when it is performed in conjunction with EES. If these services are itemized, the charges should be combined under procedure code 93618.

Catheter Ablation
Catheter ablation is an eligible procedure when performed for the indications specific to each of the following procedure codes:

Procedure code 93650 is eligible for the following indications:

• Paroxysmal supraventricular tachycardia
• Radiofrequency catheter ablation or modification of the atrioventricular junction for ventricular rate control of symptomatic atrial tachyarrhythmias
• Symptomatic sustained atrioventricular nodal reentrant tachycardia
• Atrial tachycardia or atrial flutter
• Atrial ablation for elimination of atrial fibrillation

Procedure code 93651 is eligible for the following indications:

• Paroxysmal supraventricular tachycardia
• Supraventricular tachycardia
• Accessory bypass tract arrhythmia (Wolff-Parkinson-White Syndrome)
• Symptomatic sustained atrioventricular nodal reentrant tachycardia
• Atrial tachycardia or atrial flutter
• Ischemic or idiopathic cardiomyopathy with ventricular tachycardia
• Atrial ablation for elimination of atrial fibrillation

Procedure code 93652 is eligible for the following indications:

• Patients without structural heart disease (i.e., ischemic or idiopathic cardiomyopathy) with symptomatic sustained monomorphic ventricular tachycardia; or bundle branch reentrant ventricular tachycardia
• Ischemic or idiopathic cardiomyopathy with ventricular tachycardia

Procedure code 93799 is eligible for the following indications:

• Pulmonary vein isolation for management of atrial fibrillation

Other uses of radiofrequency catheter ablation are considered not medically necessary and, therefore, not eligible for payment.

Operative Ablation
Operative ablation (33250, 33251, 33261) is an eligible surgical service which may be used to eliminate arterioventricular conduction defects.

The MAZE procedure (33254, 33255, 33256, 33257, 33258, 33259) entails making incisions in the heart that:

• direct an impulse from the sinoatrial (SA) node to the atrioventricular (AV) node;
• preserve activation of the entire atrial myocardium; and
• block reentrant impulses that are responsible for atrial fibrillation or flutter.
  

For the endoscopic approach, 33265 or 33266 should be reported.

The eligibility of the MAZE procedure should be determined on an individual consideration (IC) basis. Medical records must indicate that the patient did not respond to other medical treatments or those treatments were contraindicated.

Services that do not meet the medical necessity guidelines on this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Description

Diagnostic Endocardial Electrical Stimulation (EES)
Diagnostic endocardial electrical stimulation (pacing), also called programmed electrical stimulation of the heart, is a covered diagnostic medical service when used for patients with severe cardiac arrhythmias. The principal use for EES is in the diagnosis and treatment of sustained ventricular tachycardia. EES is also employed to study cardiac arrhythmias and to identify patients at risk of sudden arrhythmic death.

EES includes the insertion of intracardiac electrode catheters, intracardiac and extracardiac recordings, and a stimulator device. In addition, an intra-catheter HIS bundle cardiogram (93600) is usually obtained during EES, as are conventional electrocardiograms (93000).

Catheter Ablation
Catheter ablation (93650-93652), is a therapeutic technique using a tripolar electrode catheter to eliminate conduction defects. This technique involves a high level of current which is channeled through a catheter to burn and destroy the arrhythmic area of the heart. This procedure is performed on those patients who prove resistant or intolerant to pharmacological care or other means of treatment.

Operative Ablation
This procedure is performed through an incision to ablate (destroy) the arrhythmic area of the heart.

The MAZE procedure (33254, 33255, 33256, 33257, 33258, 33259) represents the surgical treatment of atrial fibrillation or flutter for patients who do not respond to medical treatment.

MAZE ablation and reconstruction can be either limited or extensive.

Limited operative ablation and reconstruction include:

1. Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.

Extensive operative ablation and reconstruction include:

1. The services included in “limited” above;
2. Additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias. This must include operative ablation that involves the right atrium, the atrial septum, or left atrium in continuity with the atrioventricular annulus.

MAZE can also be performed through an endoscopic approach (33265, 33266).

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.