Anthem Blue Cross Connecticut CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins Form

This document addresses transcatheter ablation of arrhythmogenic foci in the pulmonary veins for the treatment of atrial fibrillation or atrial flutter.

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

• CG-SURG-05 Maze Procedure
• CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
• SURG.00126 Irreversible Electroporation

Clinical Indications

Medically Necessary:

Transcatheter ablation of arrhythmogenic foci in the pulmonary veins is considered medically necessary as a treatment of symptomatic individuals with one of the following:

1. Recurrent (2 or more episodes) paroxysmal (terminates spontaneously or with intervention within 7 days of onset) atrial fibrillation as an alternative to medical therapy; or
2. Persistent (sustained greater than 7 days) atrial fibrillation when refractory or intolerant to one or more antiarrhythmic drugs (or has a contraindication to all appropriate antiarrhythmic drug therapy).

Not Medically Necessary:

Transcatheter ablation of arrhythmogenic foci in the pulmonary veins is considered not medically necessary when the medically necessary criteria are not met and for all other indications.