Mountain State Medical Policy Bulletin
Section: Diagnostic Medical
Number: M-18
Topic: Diagnostic Endocardial Electrical Stimulation (EES) Vs. Ablation Procedures
Effective Date: October 1, 2005
Issued Date: October 3, 2005
Date Last Reviewed: 11/2005

General Policy Guidelines

Indications and Limitations of Coverage

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 any of the following indications:



Indication

Procedure Codes

ICD-9 Code
Paroxysmal supraventricular tachycardia 93650, 93651 427.0
"Normal" supraventricular tachycardia 93651 426.81, 426.82
Accessory bypass tract arrhythmia (Wolff-Parkinson-White Syndrome) 93651 426.7
Radiofrequency catheter ablation or modification of the atrioventricular junction for ventricular rate
control of symptomatic atrial tachyarrhythmias		 93650 427.89
Symptomatic sustained atrioventricular nodal reentrant tachycardia 93650, 93651 426.89
Atrial tachycardia or atrial flutter 93650, 93651 427.32
Patients without structural heart disease (i.e., ischemic or idiopathic cardiomyopathy) with symptomatic sustained monomorphic ventricular tachycardia; or bundle branch reentrant ventricular tachycardia 93652 427.1
Ischemic or idiopathic cardiomyopathy with ventricular tachycardia 93651, 93652 414.8, 425.4
Atrial ablation for elimination of atrial fibrillation 93650, 93651 427.31
Pulmonary vein isolation 93799 427.31


Other uses of radiofrequency catheter ablation are considered experimental/investigational and, therefore, not eligible for payment. Scientific evidence does not demonstrate the efficacy of catheter ablation for uses other than those listed above.

Operative Ablation
Operative ablation (codes 33250-33261) is an eligible surgical service which may be used to eliminate arterioventricular conduction defects (426.0, 426.10-426.13).

The Maze procedure (33253) 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.
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.

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 (codes 93600) is usually obtained during EES, as are conventional electrocardiograms (code 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 (code 33253) represents the surgical treatment of atrial fibrillation or flutter (427.31-427.32) for patients who do not respond to medical treatment.


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.

Procedure Codes

332503325133253332619361893650
936519365293799   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Radiofrequency catheter ablation used for conditions other than those listed as eligible on this policy is considered an eligible service when determined medically necessary based on the patient’s condition. In addition, radiofrequency catheter ablation of pulmonary veins for atrial fibrillation may be considered an eligible service when determined to be medically necessary based on the patient's condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

PRN References

10/1993, Catheter ablation, reimbursement and codes for
12/1995, Intracardiac catheter ablation, reimbursement for 1
02/1996, Maze procedure, code and reporting of
10/2001, Catheter ablation

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[Version 001 of M-18]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.