126 Form

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Medical Policy Catheter Ablation for Cardiac Arrhythmias
Table of Contents • Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History • Endnotes Policy Number: 126 BCBSA Reference Number: 2.02.01A NCD/LCD: N/A Related Policies
• Catheter Ablation as Treatment for Atrial Fibrillation, #141 • Implantable Cardioverter Defibrillator (ICD), #070 • Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, #334 • Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), #356

Note: This policy does not address catheter ablation for atrial fibrillation. Refer to medical policy #141 Catheter Ablation as Treatment for Atrial Fibrillation for coverage information. Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members

Catheter ablation may be considered MEDICALLY NECESSARY for the treatment of supraventricular tachyarrhythmias, as follows:

• Treatment of paroxysmal supraventricular tachycardia due to atrioventricular nodal reentry tachycardia
• Treatment of paroxysmal supraventricular tachycardia due to accessory pathways
• Treatment of atrial flutter
• Treatment of focal atrial tachycardia, AND
• Treatment of Wolff-Parkinson-White (WPW) syndrome1 o Who are asymptomatic, AND o Who are at high risk of life-threatening arrhythmias as determined by the persistence of a delta wave during an exercise tolerance test in which a maximal heart rate is achieved.

Catheter ablation using radiofrequency energy may be considered MEDICALLY NECESSARY for the treatment of chronic, recurrent, ventricular tachycardia that is refractory to implantable cardioverter defibrillator treatment and antiarrhythmic medications, and for which an identifiable arrhythmogenic focus

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can be identified.

Catheter ablation for ventricular tachycardia storm (see Policy Guidelines section) may be considered MEDICALLY NECESSARY when pharmacologic treatment has been unsuccessful in controlling the arrhythmia.

Catheter ablation for all other ventricular arrhythmias is considered INVESTIGATIONAL.

Policy Guidelines
Catheter ablation may be considered first-line treatment of the supraventricular tachyarrhythmias noted above, ie, individuals do not need to have failed medical therapy to be considered for catheter ablation.

Permanent pacemaker implantation may be necessary following catheter ablation for supraventricular arrhythmias.

Ventricular tachycardia storm, also known as incessant ventricular tachycardia, is defined as at least 3 episodes of sustained ventricular tachycardia in a 24-hour period. Ventricular tachycardia storm is considered life-threatening and requires prompt attention and treatment.

Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary) and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular

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connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re- entry 93654 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed 93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description I45.6 Pre-excitation syndrome I47.0 Re-entry ventricular arrhythmia I47.10 Supraventricular tachycardia, unspecified I47.11 Inappropriate sinus tachycardia, so stated I47.19 Other supraventricular tachycardia I47.20 Ventricular tachycardia, unspecified I47.21 Torsades de pointes I47.29 Other ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.92 Unspecified atrial flutter I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.3 Ventricular premature depolarization Description CATHETER ABLATION
Catheter ablation has been used as a treatment for cardiac arrhythmias for several decades. Radiofrequency energy is the most commonly used source, although other energy sources (eg, cryoablation) have also been used. The technique treats supraventricular tachycardias by partially or fully ablating the atrioventricular node or accessory conduction pathways, thus ablating the arrhythmogenic focus. It controls idiopathic ventricular tachycardia or reentrant ventricular tachycardias by eliminating the focus.

Ablation is preceded by preprocedural imaging and mapping of the focus during electrophysiologic studies. Imaging and anatomic mapping systems recreate the 3-dimensional structure of the cardiac chambers. This imaging assists the electrophysiologist in defining the individual anatomy, locating the electroanatomic location of arrhythmogenic foci, and positioning the ablation catheter for delivery of radiofrequency energy. There are a variety of approaches to preprocedural imaging and mapping. Most commonly computed tomographic angiography and/or magnetic resonance imaging are used. Mapping can be done by an electroanatomic technique, by using multielectrode arrays, or by variations of these approaches.

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Anticoagulation is indicated for some patients undergoing ablation. In general, ablations involving the right side of the heart for supraventricular arrhythmias do not require anticoagulation. Ablations in the left side of the heart are often combined with anticoagulation during and/or after the procedure. There are no standardized guidelines for which patients should receive anticoagulation or for the duration of therapy.

Cardiac Catheter Ablation Complications
Catheter ablation is invasive in that a catheter is passed into the heart via an arm or leg vein. The risks of catheter ablation vary with the specific type of procedure performed; risks are also affected by whether there are underlying structural abnormalities of the heart. Various complications have been documented, which include the following:
• Vascular injury. Injury can occur to the peripheral vessels at the site of vascular access, with resulting hemorrhage, arteriovenous fistula, and/or pseudoaneurysm formation. Venous injury may lead to deep venous thrombosis, with the attendant risk of pulmonary embolism. Significant vascular injury has been estimated to occur in approximately 2% of ablation procedures.
• Cardiac tamponade. Perforation of the myocardium can lead to bleeding into the pericardial space and cardiac tamponade. This complication is estimated to occur in approximately 1% of ablation procedures and may require pericardiocentesis for treatment.
• Myocardial ischemia/infarction. Ischemia or infarction can result from damage to the coronary arteries during the procedure or from demand ischemia as a result of the procedure. The rate of these complications is not well characterized.
• Thromboembolism. Destruction of tissue by radiofrequency energy promotes thrombus formation. Thromboembolism following ablation most commonly leads to stroke or transient ischemic attack. The estimated incidence of stroke or transient ischemic attack following catheter ablation is 1.3%.
• Heart failure. Heart failure can be precipitated by “stunning” of myocardium following ablation and/or by the saline administration required during the procedure. Patients who are at risk for this complication are mostly those with preexisting left ventricular dysfunction. Patients undergoing large ablations of the left ventricle are at greatest risk.
• Radiation exposure. In any ablation procedure using radiofrequency energy, the patient is exposed to radiation from fluoroscopy. Systems intended to reduce radiation exposure (eg, electroanatomic mapping, remote navigation systems) are available.

Summary Catheter ablation is a technique to eliminate cardiac arrhythmias by selectively destroying a portion of myocardium or conduction system tissue that contains the arrhythmogenic focus. A variety of energy sources can be used with catheter ablation, such as radiofrequency and/or cryotherapy.

Supraventricular Arrhythmia For individuals who have supraventricular arrhythmias who receive catheter ablation, the evidence includes a randomized controlled trial (RCT) and numerous case series and uncontrolled trials. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Clinical series of paroxysmal supraventricular tachycardia have reported very high success rates at well over 90%. Serious complications, mainly atrioventricular block requiring pacemaker insertion, occur in approximately 1% of patients. High success rates are also reported for atrial flutter and focal atrial tachycardia. There are few comparative or trial data. The RCT assessing catheter ablation of the accessory pathway confirmed that incidence of arrhythmic events is greatly reduced with catheter ablation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Ventricular Arrhythmia For individuals with drug- and implantable cardioverter defibrillator (ICD)refractory ventricular tachycardia (VT) due to structural heart disease who receive catheter ablation, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Across 10 individual RCTs that compared catheter ablation with usual care (medical management) and 1 RCT that directly compared escalation of antiarrhythmic medications with catheter ablation in patients who had VTs and an

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automatic ICD, the evidence has shown that procedural success is 80% to 90%, and that catheter ablation is successful at reducing the number of VT episodes by about 30%. The evidence has further shown that catheter ablation is associated with approximately a 50% reduction in inappropriate ICD interventions compared with usual medical management alone. The rate of serious procedural adverse events is low. Late recurrences do occur, but most patients treated with ablation remain free of VT at 1- to 2-year follow-ups and 40% to 50% remain VT-free after 6 years of follow-up. The trial directly comparing catheter ablation with the escalation of medication found a 28% lower rate of a composite of death, VT storm, and appropriate ICD shock among patients undergoing catheter ablation vs those receiving an escalation in antiarrhythmic drug therapy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have idiopathic VT refractory to drug therapy and ICD placement who receive catheter ablation, the evidence includes a few case series. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. There are no comparative or trial data and, given the rarity of the disease, such RCTs are unlikely. Case series have reported high success rates and low adverse event rates with catheter ablation. However, the body of literature is small. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have VT storm who have failed pharmacologic treatment who receive catheter ablation, the evidence includes a few case series. Relevant outcomes are overall survival, symptoms, change in disease status, morbid events, medication use, and treatment-related morbidity. Serious complications have been reported at reasonably low rates, and mortality from the procedure was reported to be 0.6% in a meta-analysis of case series. There are no comparative or trial data. Because of the emergent nature of this condition, RCTs are not expected to be performed. In these situations, morbidity and mortality are expected to be extremely high in patients who have failed pharmacologic therapy; therefore, catheter ablation is expected to reduce morbidity and mortality. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Clinical input obtained in 2012 has supported the use of catheter ablation to treat VT and other ventricular arrhythmias.

Policy History Date Action 12/2025 Medical policy 126 describing medically necessary and investigational indications reinstated. Effective 12/1/2025.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

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      Endnote

      1 Based on expert opinion