356 Form

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Medical Policy Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 356

BCBSA Reference Number: 7.01.14 (For Plan internal use only) NCD/LCD: N/A Related Policies
• Catheter Ablation as Treatment of Atrial Fibrillation, #141 • Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, #334 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

The maze procedure or modified procedure, performed on a non-beating heart during cardiopulmonary bypass with concomitant cardiac surgery, is considered MEDICALLY NECESSARY for the treatment of symptomatic atrial fibrillation or flutter.

Stand-alone minimally invasive, off-pump maze procedures (ie, modified maze procedures), including those done via mini-thoracotomy, are considered INVESTIGATIONAL for treatment of atrial fibrillation or flutter.

Hybrid ablation (defined as a combined percutaneous and thoracoscopic approach) is considered INVESTIGATIONAL for the treatment of atrial fibrillation or flutter.

The use of an open maze or modified maze procedure performed on a non‒beating heart during cardiopulmonary bypass without concomitant cardiac surgery is considered NOT MEDICALLY NECESSARY for treatment of symptomatic atrial fibrillation or flutter.

Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient

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• 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) This procedure is performed in the inpatient setting Commercial PPO and Indemnity This procedure is performed in the inpatient setting Medicare HMO BlueSM This procedure is performed in the inpatient setting Medicare PPO BlueSM This procedure is performed in the inpatient setting 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 following codes are included below for informational purposes only; this is not an all-inclusive list.

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 33256 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); with cardiopulmonary bypass 33257 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (e.g., modified maze procedure) (List separately in addition to code for primary procedure) 33259 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) ICD-10 Procedure Codes ICD-10 procedure codes: Code Description 02560ZZ Destruction of Right Atrium, Open Approach 02563ZZ Destruction of Right Atrium, Percutaneous Approach 02570ZZ Destruction of Left Atrium, Open Approach 02573ZZ Destruction of Left Atrium, Percutaneous Approach

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes: Code Description 33254 Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure) 33255 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); without cardiopulmonary bypass

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33258 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) 33265 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass 33266 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., maze procedure), without cardiopulmonary bypass

Description Atrial Fibrillation Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by disorganized atrial activation with ineffective atrial ejection. The underlying mechanism of AF involves the interplay between electrical triggering events that initiate AF and the myocardial substrate that permits propagation and maintenance of the aberrant electrical circuit. The most common focal trigger of AF appears to be located within the cardiac muscle that extends into the pulmonary veins. The atria are frequently abnormal in patients with AF and demonstrate enlargement or increased conduction time. Atrial flutter is a variant of AF. Epidemiology In the US, more than 3 to 6 million people have AF and it has been estimated that more than 12 million people will have AF by 2030.1,2,3, Age, body mass index, height, hypertension, diabetes mellitus, obstructive sleep apnea, myocardial infarction, heart failure, hyperthyroidism, chronic kidney disease, smoking, moderate to heavy alcohol consumption, and genetic predisposition are all risk factors for AF.4,3, Age-adjusted AF incidence and prevalence is higher among men than women, although the lifetime risk is similar at 24% for men and 22% for women5,. AF incidence and prevalence appear lower in individuals who are Black compared to White, despite a higher burden of comorbidities. However, this difference is likely largely explained by differential detection of AF by race/ethnicity.6,

Treatment The first-line treatment for AF usually includes medications to maintain sinus rhythm and/or control the ventricular rate. Antiarrhythmic medications are only partially effective; therefore, medical treatment is not sufficient for many patients. Percutaneous catheter ablation, using endocardial ablation, is an accepted second-line treatment for patients who are not adequately controlled on medications and may also be used as first-line treatment. Catheter ablation (CA) is successful in maintaining sinus rhythm for most patients, but long-term recurrences are common and increase over time. Performed either by open surgical techniques or thoracoscopy, surgical ablation is an alternative approach to percutaneous CA.

Summary There are various surgical approaches to treat atrial fibrillation (AF) that work by interrupting abnormal electrical activity in the atria. Open surgical procedures, such as the Cox maze procedure were first developed for this purpose and are now generally performed in conjunction with valvular or coronary artery bypass graft surgery. Surgical techniques have evolved to include minimally invasive approaches that use epicardial radiofrequency ablation, a thoracoscopic or mediastinal approach, and hybrid catheter ablations/open procedures. For individuals who have symptomatic atrial fibrillation (AF) or flutter who are undergoing cardiac surgery with bypass who received a Cox maze or a modified maze procedure, the evidence includes several randomized controlled trials (RCTs) and nonrandomized comparative studies, along with systematic reviews of these studies. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. Several small RCTs have provided most of the direct evidence confirming the benefit of a modified maze procedure for patients with AF who are undergoing mitral valve surgery. These trials have established that the addition of a modified maze procedure results in a lower incidence of atrial arrhythmias following surgery, with minimal additional risks. Observational studies have supported these RCT findings. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals who have symptomatic, drug-resistant AF or flutter who are not undergoing cardiac surgery with bypass who receive minimally invasive, off-pump thoracoscopic maze procedures, the evidence includes RCTs and observational studies, some of which identify control groups. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. Two RCTs reported significantly higher rates of freedom from AF at 1-year with surgical ablation but also reported significantly higher rates of serious adverse events. The remaining 2 RCTs found no significant differences between treatment groups in rates of freedom from AF and either did not assess or did not find significant differences in serious adverse events. The comparative observational studies consistently found significantly higher rates of freedom from atrial arrhythmias but lacked assessment of serious adverse events. The noncomparative studies generally only reported short-term outcomes and did not consistently report adverse events. Therefore, this evidence does not permit definitive conclusions about whether a specific approach is superior to the other. Factors, such as previous treatment, the probability of maintaining sinus rhythm, the risk of complications, contraindications to anticoagulation, and patient preference, may all affect the risk-benefit ratio for each procedure. Additionally, the studies do not permit conclusions about harm due to heterogeneous measurement across studies, with mixed results. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have symptomatic, drug-resistant AF or flutter who are not undergoing cardiac surgery with bypass who receive hybrid thoracoscopic and endocardial ablation procedures, the evidence includes 5 RCTs (sample sizes ranging from 41 to 154), comparative observational studies, single-arm case series, and systematic reviews of these studies. Relevant outcomes are overall survival, medication use, and treatment-related morbidity. Evidence from randomized and nonrandomized studies found an increased rate of AF-free survival, reduced risk of cardioversion, and increased risk of periprocedural adverse events with hybrid procedures relative to standard ablation. The largest RCT (CEASE-AF) reported composite major complications at 1 year in 9% vs 6% and at 2 years in 10.8% and 9.6% with hybrid vs standard ablation. Although the surgical ablation lesion sets varied across studies and have not been standardized in practice, many professional organizations including the American Heart Association and the Heart Rhythm Society make conditional recommendations that hybrid ablation procedures might be reasonable to reduce the risk of recurrent atrial arrhythmia after careful consideration of relative safety and efficacy of treatment options based on available evidence. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 5/2026 Annual policy review. Policy updated with literature review through February 4, 2026; references added. Policy statements unchanged. 5/2025 Annual policy review. Summary and references updated. Policy statements unchanged. 5/2024 Clarified prior authorization table 7/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2017 Annual policy review. “Drug resistant” removed from medically necessary statement and not medically necessary statement. Effective 10/1/2017. 7/2016 Annual policy review. New references added. 12/2015 Annual policy review. New not medically necessary indications described. The phrase “without concomitant cardiac surgery” was removed from the medically

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necessary policy statement. Title revised to include Atrial Flutter. Clarified coding information. Effective 12/1/2015. 9/2014 Annual policy review. New references added. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes. Effective 10/2015. 1/2014 Annual policy review. New investigational indications described. Effective 1/1/2014. 12/2013 Removed ICD-9 diagnosis codes 427.31, 427.32 as the policy is requires prior authorization. 7/2013 Annual policy review. Added “or modified” and “(i.e., modified maze procedures)” to the policy statements. Effective 7/1/2013. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 4/2010 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 4/2009 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 4/2008 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 8/2007 Annual policy review. Changes to policy statements. 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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49. Harlaar N, Oudeman MA, Trines SA, et al. Long-term follow-up of thoracoscopic ablation in long- standing persistent atrial fibrillation. Interact Cardiovasc Thorac Surg. Jun 01 2022; 34(6): 990-998. PMID 34957518
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57. PMID 34887950
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67. Doll N, Weimar T, Kosior DA, et al. Durable effectiveness and safety of hybrid ablation versus catheter ablation: 2-year results from the randomized CEASE-AF trial†. Eur J Cardiothorac Surg. Jul 01 2025; 67(7). PMID 40711852
68. Kress DC, Erickson L, Choudhuri I, et al. Comparative Effectiveness of Hybrid Ablation Versus Endocardial Catheter Ablation Alone in Patients With Persistent Atrial Fibrillation. JACC Clin Electrophysiol. Apr 2017; 3(4): 341-349. PMID 29759446

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68. Maclean E, Yap J, Saberwal B, et al. The convergent procedure versus catheter ablation alone in longstanding persistent atrial fibrillation: A single centre, propensity-matched cohort study. Int J Cardiol. Mar 15 2020; 303: 49-53. PMID 32063280
69. Pannone L, Mouram S, Della Rocca DG, et al. Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience. Europace. May 19 2023; 25(5). PMID 37246904
70. Yu C, Li H, Zeng Z, et al. Hybrid Biatrial Ablation Versus Catheter Ablation for Patients With Nonparoxysmal Atrial Fibrillation and Enlarged Left Atrium. Innovations (Phila). 2024; 19(5): 511-519. PMID 39305170
71. Lorenzo C, Ortiz-Gonzalez Y, Hill D, et al. Real-world evidence demonstrates an appropriate atrial fibrillation population for hybrid convergent approach versus stand-alone cryoballoon ablation: A long- term safety and efficacy study. J Cardiovasc Electrophysiol. Aug 2024; 35(8): 1624-1632. PMID 38898656
72. Mannakkara NN, Porter B, Child N, et al. Convergent ablation for persistent atrial fibrillation: outcomes from a single-centre real-world experience. Eur J Cardiothorac Surg. Dec 02 2022; 63(1). PMID 36346176
73. Kiankhooy A, Pierce C, Burk S, et al. Hybrid ablation of persistent and long-standing persistent atrial fibrillation with depressed ejection fraction: A single-center observational study. JTCVS Open. Dec 2022; 12: 137-146. PMID 36590727
74. Gehi AK, Mounsey JP, Pursell I, et al. Hybrid epicardial-endocardial ablation using a pericardioscopic technique for the treatment of atrial fibrillation. Heart Rhythm. Jan 2013; 10(1): 22-8. PMID 23064043
75. Gersak B, Pernat A, Robic B, et al. Low rate of atrial fibrillation recurrence verified by implantable loop recorder monitoring following a convergent epicardial and endocardial ablation of atrial fibrillation. J Cardiovasc Electrophysiol. Oct 2012; 23(10): 1059-66. PMID 22587585
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