Anthem Blue Cross Connecticut Commercial Clinical Policy

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

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



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.