Anthem Blue Cross Connecticut CG-SURG-05 Maze Procedure Form

This document addresses the use of the Maze procedure as a curative surgical treatment of atrial fibrillation or flutter for individuals who do not respond to medical therapies. The Maze procedure, also known as the Cox-Maze procedure, involves creating sequential atriotomy lesions. These lesions interrupt potential re-entrant circuits and reestablish activation of the entire atrial myocardium, restoring its transport function. Lesions can be made using cryoablation, radiofrequency or less commonly, surgical incisions.

Note: Please see the following document for additional information regarding implantation of a left atrial appendage (LAA) occlusion device performed in conjunction with another open cardiac surgical procedure:

• SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention

Note: Please see the following related documents for additional information:

• CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation

Clinical Indications

Medically Necessary:

The Maze procedure is considered medically necessary for drug resistant atrial fibrillation or flutter.

The Maze procedure is considered medically necessary for individuals with highly symptomatic atrial fibrillation who require open heart surgery for valvular, ischemic, or congenital heart disease.

Not Medically Necessary:

The Maze procedure is considered not medically necessary for all other indications.