THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation Form

This document addresses the use of electrophysiology-guided noninvasive stereotactic cardiac radioablation, also known as stereotactic arrhythmia radiotherapy (STAR), as a treatment modality for cardiac arrhythmias, including drug and ablation refractory ventricular tachycardia (VT) and cardiomyopathy related to premature ventricular contractions (PVC).

Note: For more information on the treatment of cardiac arrythmias, please see the following:

• CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
• CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
• CG-SURG-97 Cardioverter Defibrillators

Position Statement

Investigational and Not Medically Necessary:

The use of electrophysiology-guided noninvasive stereotactic cardiac radioablation is considered investigational and not medically necessary as a treatment modality for all indications, including drug and ablation refractory ventricular tachycardia and cardiomyopathy related to premature ventricular contractions.