Anthem Blue Cross Connecticut CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation Form

This document addresses two cardiac electrophysiological procedures and studies, including electrophysiological studies (EPS) and catheter ablation. EPS with programmed ventricular stimulation (PVS) is used as a complement to a full workup, to document the inducibility and type of induced arrhythmia, (for example, atrial fibrillation, ventricular tachycardia, etc.). EPS is also used to assess the risks for recurrent ventricular tachycardia or sudden cardiac death; to evaluate symptoms, such as syncope; and to guide catheter ablation procedures in selected individuals when arrhythmias are suspected to be the etiology. EPS can also be used, in appropriate individuals, for the purpose of assessment for eligibility for treatments, such as implantable cardioverter defibrillator therapy.

Note:This document addresses non-emergent elective EPS and catheter ablation procedures only.

Note: This document does not address transcatheter ablation of arrhythmogenic foci in the pulmonary veins.

For information related to other technologies associated with cardiac disease evaluation or management, see:

• CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• CG-SURG-97 Cardioverter Defibrillators
• CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)

Clinical Indications

Medically Necessary:

Cardiac electrophysiological procedures and studies may include the following when criteria are met (A and B):

1. Electrophysiological studies (EPS); and
2. Intracardiac catheter ablation.

EPS are considered medically necessary for ANY of the following indications when criteria are met (A through G):

1. For the evaluation of syncope in individuals with any of the following (1 through 7):
   1. Ischemic heart disease or structural heart disease based on prior positive history, physical examination, and noninvasive testing (for example, electrocardiography, echocardiography) and with impaired left ventricular (LV) function (left ventricular ejection fraction [LVEF] less than or equal to 35%); or
   2. For risk stratification in coronary artery disease (CAD) in survivors of myocardial infarction (MI) with preserved LV function (LVEF greater than 35%); or
   3. Sinus bradycardia suspected to be associated with Sick Sinus Syndrome (SSS); or
   4. When bradyarrhythmias or tachyarrhythmias are suspected as the cause of symptoms with inconclusive prior test results, particularly in the setting of structural heart disease; or
   5. Bifascicular block (left or right bundle branch block [BBB] and hemifascicular block) when prior noninvasive testing has been inconclusive or equivocal; or
   6. Cardiac sarcoidosis and syncope of suspected arrhythmic etiology; or
   7. Moderate or severe adult congenital heart disease (CHD) with unexplained syncope

or

2. In survivors of sudden cardiac death (SCD) when no diagnostic cause has been confirmed by medical history or prior testing or when Pre-excitation Syndrome, (for example, Wolff-Parkinson-White [WPW]) is suspected;
   
   or
    
3. For the evaluation of supraventricular tachyarrhythmias (SVT) when criteria 1 or 2 are met:
   1. For the evaluation of symptomatic paroxysmal SVT without an identifiable reversible cause; or
   2. To identify and localize the arrhythmic substrate when the SVT is recurrent, symptomatic and refractory to medical management with any of the following (a through f):
      1. Suspected Pre-excitation Syndrome, (such as WPW); or
      2. Suspected accessory pathways as the cause of the SVT; or
      3. Adult individuals with congenital heart disease (CHD); or
      4. Atrial flutter; or
      5. Paroxysmal or persistent Atrial fibrillation (AF); or
      6. AF when symptomatic due to paroxysmal, recurrent or persistent AF for any of the following (i. through iii.):
         1. Hypertrophic cardiomyopathy (HCM); or
         2. With Pre-excitation syndrome (such as WPW) with an accessory pathway; or
         3. Heart failure (NYHA Class II or III) with tachycardia-induced cardiomyopathy (CM) with LVEF less than or equal to 35% when AV nodal ablation is planned (with permanent ventricular pacing);

or

4. For the evaluation of symptomatic recurrent sustained or nonsustained ventricular tachycardia (VT) that is predominantly monomorphic to determine the source of the arrhythmic substrate when refractory to medical management and implantable cardioverter defibrillator (ICD) therapy (or not a candidate for ICD) for any of the following (1 through 8):
   1. CAD with or without prior history of MI when  symptoms are suspicious for VT (for example, palpitations, presyncope, syncope); or
   2. CHD when either of the following are present (a or b):
      1. LV dysfunction (LVEF equal to or less than 35%) and frequent premature ventricular contractions (PVCs) to assess the efficacy of catheter ablation; or
      2. In individuals with an ICD who do not wish long-term drug therapy; or
   3. Structural heart disease with LV dysfunction (LVEF equal to or less than 35%) and frequent PVCs; or
   4. Dilated cardiomyopathy (DCM) with bundle branch re-entrant VT episodes; or
   5. Predominantly monomorphic PVC-induced CM manifested by high PVC burden (greater than 24%) with LV dysfunction (LVEF equal to or less than 35%) and a short coupling interval of the PVCs (less than 300 ms); or
   6. Ischemic heart disease as adjunctive therapy in individuals with an ICD who are receiving multiple shocks as a result of  sustained VT that is not manageable by reprogramming the ICD or changing drug therapy or who do not wish long-term drug therapy; or
   7. Following valvular surgery with bundle branch re-entry VT; or
   8. PVCs triggering recurrent ventricular fibrillation (VF) leading to ICD interventions.

or

5. In children and adolescents less than 18 years of age with any of the following conditions (1 through 6):
   1. Incessant or recurrent SVT associated with ventricular dysfunction; or
   2. With frequent PVCs or VT thought to be causative of ventricular dysfunction; or
   3. In symptomatic idiopathic right ventricular outlet tract (RVOT)-VT/PVCs or verapamil-sensitive left fascicular VT or with declining LV function due to RVOT-PVC burden when medical management has been ineffective or not well tolerated; or
   4. In symptomatic idiopathic left ventricular outflow tract (LVOT), aortic cusps or epicardial VT/PVC when medical management has failed or as an alternative to chronic medical management; or
   5. As additional therapy or as an alternative to ICD in individuals with CHD who have recurrent monomorphic VT or appropriate ICD therapies that are not manageable by device reprogramming or drug therapy; or
   6. In suspected Pre-excitation Syndrome, (such as WPW).

or

6. For management or evaluation of individuals with any of the following (1 through 5):
   1. Pre-excitation that is asymptomatic to risk stratify for arrhythmic events; or
   2. Idiopathic VT: palpitations or suspected outflow tract VT in the absence of structural heart disease; or
   3. LVOT/aortic cusp/epicardial VT/PVCs that is symptomatic and refractory to medical management or in individuals not wanting long-term anti-arrhythmic drug therapy; or
   4. Papillary muscle tachycardia or mitral and tricuspid annular tachycardia that is symptomatic and refractory to medical management or who do not wish long-term drug therapy; or
   5. Accessory pathways or atrial tachycardia (AT) in individuals with SVT who are undergoing surgical repair of Ebstein anomaly;

or

7. For the evaluation of first line rhythm control treatment (that is, before medical management has been tried for treatment of the arrhythmia and proven to be ineffective) in individuals with any of the following (1 through 8):
   1. Recurrent symptomatic paroxysmal AF; or
   2. Recurrent symptomatic non-cavotricuspid isthmus (non-CTI) dependent atrial flutter; or
   3. CTI-dependent atrial flutter, symptomatic or refractory to pharmacological rate control; or
   4. Recurrent symptomatic AV nodal re-entrant tachycardia (AVNRT); or
   5. An accessory pathway and symptomatic arrhythmias including orthodromic AV re-entry tachycardia (AVRT), antidromic AVRT, and pre-excited AF or atrial flutter; or
   6. Symptomatic idiopathic left VTs; or
   7. Symptomatic focal AT; or
   8. Frequent non-sustained ventricular arrhythmias (for example, PVC 10,000 per 24 hours with significant symptoms or LV dysfunction [LVEF equal to or less than 35%]).

Cardiac catheter ablation is considered medically necessary for the treatment of arrhythmias associated with any of the above indications when the source of the arrhythmic substrate is identified and localized by EPS studies and considered amenable to ablation treatment.

Note: See Definitions section for detailed information about the classifications of AF and other terminology.

Not Medically Necessary:

Cardiac EPS and catheter ablation procedures are considered not medically necessary when the criteria are not met and for all other applications, including for risk stratification for SCD in HCM and other cardiac conditions not included in the medically necessary criteria in this document.