Humana Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Form

. Cardiac electrophysiological studies (EPS) are tests that help determine an arrhythmia’s (abnormal rhythm) area of origin in the heart. Arrhythmias are caused by damage to the heart related to disease, genetics or injury which changes the electrical signals that control cardiac activity. This damage may result from myocardial infarction (heart attack), aging, high blood pressure or abnormal electrical pathways created by certain congenital defects. EPS usually take place in an electrophysiology (EP) lab or a cardiac catheterization lab while the individual is mildly sedated. A catheter (thin tube) is inserted into a blood vessel leading to the heart. This catheter contains specialized electrodes enabling the physician to send programmed electrical stimulation to the heart and Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 2 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. record its electrical activity. The physician may also attempt to induce an arrhythmia to determine the cause or origin. Pacing can be accomplished via these electrodes if arrhythmias arise. EPS are used to diagnose arrhythmias, evaluate the effectiveness of antiarrhythmic medication, assess the risk of cardiac arrest or determine the need for potential treatment (eg, implantation of a pacemaker or implantable cardioverter defibrillator [ICD]). Cardiac catheter ablation is a procedure which may be performed in conjunction with EPS. Radiofrequency energy (heat) or cryoablation (cold) is used via catheter to restore the heart’s regular rhythm by destroying a small area of heart tissue that is causing an arrhythmia. During this procedure, three-dimensional (3D) mapping (eg, CARTO 3 System, EnSite Precision System) may be used to define the cardiac anatomy and provide guidance for ablation. Cardiac focal ablation using radiation therapy, also known as stereotactic arrhythmia radioablation (STAR), is proposed to treat ventricular arrhythmias (eg, ventricular tachycardia [VT]) when medication or catheter ablation are ineffective or contraindicated. This investigational therapy fuses noninvasive electrocardiogram (ECG) and imaging (eg, computed tomography, magnetic resonance, positron emission tomography) data to pinpoint the area in the heart that is triggering the arrhythmia. High dose stereotactic radiation therapy is used to render the targeted area electrically inactive to purportedly reduce VT episodes. (Refer to Coverage Limitations section) Transcatheter pulmonary artery denervation (PADN) is a catheter ablation technique proposed to treat pulmonary artery hypertension (PAH), a condition which may lead to right heart failure. Novel PAH treatments under investigation include thermal and ultrasound catheter ablation used to target sympathetic nerve fibers in the pulmonary artery and its bifurcation. Thermal pulmonary artery denervation uses radiofrequency ablation to apply thermal energy to destroy a small area of the targeted nerve tissue. Ultrasound pulmonary artery denervation uses high frequency nonfocused ultrasound energy to ablate the targeted nerve bundles. These transcatheter procedures are purported to decrease sympathetic nervous system (SNS) activity and reduce pulmonary artery pressure. (Refer to Coverage Limitations section) See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 3 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. For information regarding cardiac catheterization, please refer to Cardiac Catheterization Medical Coverage Policy. For information regarding implantable cardioverter defibrillators, please refer to Cardioverter Defibrillators/Cardiac Resynchronization Therapy Medical Coverage Policy. Coverage Determination Humana members may be eligible under the Plan for diagnostic cardiac EPS for the following indications: • Absence of contraindications; AND • Individual with syncope and ANY of the following: o Bifascicular block (left or right bundle branch block combined with left anterior or posterior fascicular block) and inconclusive or negative noninvasive testing*; OR o Ischemic heart disease or other structural heart disease based on history, physical examination, electrocardiogram (ECG) and echocardiography; OR o Noninvasive or ambulatory monitoring is inconclusive; OR o Palpitations immediately followed by syncope; OR o Suspected sinus node dysfunction based upon inappropriate sinus bradycardia; OR • Second-degree atrioventricular (AV) block when clinical and ECG information fail to localize site of block; OR • Survivor of sudden cardiac death (SCD) with no established cause (eg, idiopathic ventricular fibrillation [VF]); OR • Wide complex tachyarrhythmias when noninvasive testing* is inconclusive See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 4 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. *Noninvasive cardiac testing includes, but may not be limited to cardiac computed tomography, echocardiogram, event monitor, Holter monitor, magnetic resonance imaging or stress test (exercise, nuclear or stress echocardiogram). Humana members may be eligible under the Plan for cardiac EPS for risk stratification for the following indications: • Absence of contraindications; AND • Asymptomatic individual 8 through 21 years of age with ECG manifestations of pre-excitation in whom clear loss of pre-excitation is not seen on exercise stress testing (indicating high risk for SCD); OR • Asymptomatic individual with second-degree AV block if site of block is undetermined; OR • Individual with unrepaired tetralogy of Fallot at high risk for SCD; OR • Primary prevention of SCD in an individual with ischemic cardiomyopathy due to prior myocardial infarction who has a left ventricular ejection fraction (LVEF) less than 40% and nonsustained (greater than or equal to 3 beats terminating spontaneously) ventricular tachycardia (VT) found on ambulatory cardiac monitoring; OR • Programmed electrical stimulation for the following: o Asymptomatic individual with arrhythmogenic right ventricular cardiomyopathy (ARVC); OR o Asymptomatic individual with class I Brugada pattern (coved ST segments with ST-segment elevation greater than 2 millimeters (mm), followed by a negative T-wave on ECG); OR o Individual with cardiac sarcoidosis and LVEF 36 – 49% and/or right ventricular ejection fraction (RVEF) less than 40% despite guideline-directed medical therapy (GDMT)** including immunosuppression53; OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 5 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Symptomatic (eg, chest pain, palpitations and/or syncope) pre-excitation in an accessory pathway **GDMT represents individualized optimal medical therapy and lifestyle modifications for cardiac sarcoidosis (with left ventricular dysfunction or heart failure) and may include the following: • Aldosterone antagonists • Angiotensin-converting enzyme inhibitors (ACEI) • Angiotensin receptor blockers (ARB) • Angiotensin receptor-neprilysin inhibitors (ARNI)15 • Beta blockers • Diuretics • Immunosuppressants • Ivabradine8 • Nitrates8 • SLGT2 inhibitors8 • Lifestyle modifications (eg, diet, exercise, smoking cessation, weight loss) Humana members may be eligible under the Plan for cardiac EPS with cardiac catheter ablation for the following indications: • Absence of contraindications; AND • Accessory pathway tachycardia (eg, Wolff-Parkinson-White [WPW] syndrome); OR • Atrial fibrillation and ALL of the following: o Catheter ablation appropriate as indicated by ANY of the following:  Accessory pathway identified; OR  Hypertrophic obstructive cardiomyopathy and antiarrhythmic medication is contraindicated, ineffective or is not tolerated; OR  Individual intolerant to rate control medications; OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 6 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.  Individual with tachy-brady syndrome/sinus node dysfunction (eg, as alternative to pacemaker implantation); OR  Symptomatic (eg, chest pain, dyspnea and/or palpitations) atrial fibrillation and BOTH of the following:  Antiarrhythmic medication is contraindicated, ineffective or is not tolerated; AND  Rhythm control desired (in addition to rate control) and is judged to be feasible (ablation has a reasonable chance of success); OR  Symptomatic (eg, chest pain, dyspnea and/or palpitations) chronic heart failure (heart failure with reduced ejection fraction [HFrEF]) despite rate control; OR  Tachycardia mediated cardiomyopathy; OR  Ventricular rate not controlled with medications; AND o Individual is able to be anticoagulated during the procedure and for at least 2 months following; AND o Reversible cause of atrial fibrillation absent (eg, hyperthyroidism); OR • Atrial flutter; OR • Focal or multifocal atrial tachycardia; OR • Junctional tachycardia when medical therapy is ineffective or contraindicated; OR • Re-entrant tachycardia (atrioventricular node or bundle branch); OR • Ventricular arrhythmia) as indicated by ANY of the following: See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 7 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. o Adult congenital heart disease with recurrent sustained (lasting more than 30 seconds) monomorphic ventricular tachycardia (VT) or recurrent appropriate ICD shocks; OR o Arrhythmogenic right ventricular cardiomyopathy and BOTH of the following:  Beta-blocker medication is contraindicated, ineffective or not tolerated; AND  Recurrent symptomatic (eg, chest pain, dyspnea and/or palpitations) sustained VT (lasting more than 30 seconds); OR o Brugada syndrome with recurrent ICD shocks for polymorphic VT; OR o Brugada syndrome with type 1 Brugada ECG pattern and BOTH of the following:  Individual is not a candidate for ICD (eg, life expectancy less than 1 year) or declines ICD; AND  Symptomatic (eg, chest pain, dyspnea and/or palpitations) sustained VT (lasting more than 30 seconds); OR o Frequent premature ventricular contractions (PVCs) (eg, greater than 15% of beats) and BOTH of the following:  Antiarrhythmic medications are contraindicated, ineffective or not tolerated; AND  Symptoms (eg, dizziness, palpitations) or declining ventricular function due to PVCs; OR o History of myocardial infarction when antiarrhythmic medications are contraindicated, ineffective or are not tolerated and EITHER of the following:  Electrical storm (eg, 3 or more episodes of sustained [lasting more than 30 seconds] VT or appropriate ICD shocks within 24 hours); OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 8 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.  Recurrent episodes of symptomatic (eg, chest pain, dyspnea, palpitations) sustained VT (lasting more than 30 seconds); OR o Ischemic heart disease (eg, known coronary artery disease) and ANY of the following:  ICD shocks for sustained (lasting more than 30 seconds) monomorphic VT; OR  Polymorphic VT or VF without reversible cause (eg, electrolyte disorder, medication, myocardial ischemia) and BOTH of the following:  Antiarrhythmic medication is contraindicated, ineffective or is not tolerated; AND  Premature ventricular complex trigger identified; OR  Recurrent symptomatic (eg, chest pain, dyspnea, palpitations) sustained (lasting more than 30 seconds) monomorphic VT; OR o Nonischemic cardiomyopathy and the following:  Antiarrhythmic medication is contraindicated, ineffective or not tolerated; AND 1 or more of the following:  Cardiac sarcoidosis with recurrent VT when medical therapy (eg, antiarrhythmic medication and/or immunosuppressants) is contraindicated, ineffective or not tolerated; OR  Electrical storm (eg, 3 or more episodes of sustained [lasting more than 30 seconds] VT or appropriate ICD shocks within 24 hours); OR  Recurrent sustained (lasting more than 30 seconds) monomorphic VT; OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.  Suspected epicardial substrate or circuit on ECG; OR Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 9 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. o Recurrent episodes of idiopathic VF or polymorphic VT initiated by PVCs with consistent QRS morphology; OR o Structurally normal heart with symptomatic (eg, chest pain, dyspnea and/or palpitations) ventricular arrhythmias (eg, idiopathic, outflow tract, papillary muscle) when antiarrhythmic medications are contraindicated, ineffective or not tolerated; OR o Verapamil-sensitive idiopathic left VT related to interfascicular re-entry and antiarrhythmic medications are contraindicated, ineffective or not tolerated5 Humana members may be eligible under the Plan for intracardiac electrophysiological 3D mapping (eg, CARTO 3 System, EnSite Precision System) when used for guiding radiofrequency cardiac catheter ablation in the treatment of arrhythmias. Coverage Limitations Humana members may NOT be eligible under the Plan for cardiac EPS and cardiac catheter ablation for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Humana members may NOT be eligible under the Plan for cardiac EPS and cardiac catheter ablation for any of the following contraindications: • Bacteremia or septicemia; OR • Inability or intolerance to lay flat or at an angle that allows safe performance of the procedure; OR • Major bleeding diathesis (eg, coagulopathies, disseminated intravascular coagulation [DIC])48; OR • Peripheral vascular disease that prohibits peripheral access; OR See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 10 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Unstable angina (acute coronary syndrome) These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language. Humana members may NOT be eligible under the Plan for the following treatments for any indication: • Cardiac focal ablation using radiation therapy (stereotactic arrhythmia radioablation [STAR]) • Thermal (radiofrequency) pulmonary artery denervation • Ultrasound pulmonary artery denervation These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language. Background Additional information about cardiac arrhythmias may be found from the following websites: • American Heart Association • National Heart, Lung and Blood Institute • National Library of Medicine Medical Alternatives Alternatives to cardiac EPS and cardiac catheter ablation include, but may not be limited to: • Electrical cardioversion • Implantable cardioverter-defibrillator (ICD) • Prescription drug therapy • Surgical ablation procedure See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 11 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Physician consultation is advised to make an informed decision based on an individual’s health needs. Provider Claims Codes Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. CPT® Code(s) 93600 93602 93603 93609 93610 93612 93613 93618 93619 93620 Description Comments Bundle of His recording Intra-atrial recording Right ventricular recording Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) Intra-atrial pacing Intraventricular pacing Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) Induction of arrhythmia by electrical pacing Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 12 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 93621 93622 93624 93631 93640 93641 93642 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 13 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 93644 93650 93653 93654 93655 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement 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 connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry 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 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) See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 14 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary, and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) Description Comments 93656 93657 CPT® Category III Code(s) 0632T 0745T 0746T Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan 0747T Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia Not Covered Not Covered New Code Effective 01/01/2023 Not Covered New Code Effective 01/01/2023 Not Covered New Code Effective 01/01/2023 See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 15 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Percutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance Description Not Covered New Code Effective 07/01/2023 Comments 0793T HCPCS Code(s) No code(s) identified References 1. 2. 3. 4. 5. 6. Agency for Healthcare Research and Quality (AHRQ). Technology Assessment. Catheter ablation for treatment of atrial fibrillation. https://www.ahrq.gov. Published April 20, 2015. Accessed March 22, 2023. American College of Cardiology (ACC). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. https://www.acc.org. Published December 2, 2014. Accessed March 27, 2023. American College of Cardiology (ACC). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. https://www.acc.org. Published April 5, 2016. Accessed March 27, 2023. American College of Cardiology (ACC). 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope. https://www.acc.org. Published August 1, 2017. Accessed March 27, 2023. American College of Cardiology (ACC). 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. https://www.acc.org. Published October 2, 2018. Accessed March 27, 2023. American College of Cardiology (ACC). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. https://www.acc.org. Published July 9, 2019. Accessed March 27, 2023. 7. American College of Cardiology (ACC). 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 16 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. https://www.acc.org. Published December 22, 2020. Accessed March 27, 2023. 8. 9. American College of Cardiology (ACC). 2022 ACC/AHA/HFSA guideline for the management of heart failure. https://www.acc.org. Published May 3, 2022. Accessed March 29, 2023. American College of Cardiology (ACC). ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. https://www.acc.org. Published May 27, 2008. Accessed March 27, 2023. 10. American College of Cardiology (ACC). Executive Summary. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias. https://www.acc.org. Published October 15, 2003. Accessed March 27, 2023. 11. American College of Cardiology (ACC). Pulmonary artery denervation for pulmonary arterial hypertension. https://www.acc.org. Published December 12, 2022. Accessed March 29, 2023. 12. American Heart Association (AHA). 2018 AHA/ACC guideline for the management of adults with congenital heart disease. https://www.heart.org. Published April 2, 2019. Accessed March 27, 2023. 13. American Heart Association (AHA). AHA Scientific Statement. Congenital heart disease in the older adult. https://www.heart.org. Published May 26, 2015. Accessed March 27, 2023. 14. American Heart Association (AHA). AHA Scientific Statement. Managing atrial fibrillation in patients with heart failure and reduced ejection fraction. https://www.heart.org. Published July 2021. Accessed March 29, 2023. 15. ClinicalKey. Calkins F, Tomaselli GF, Morady F. Atrial fibrillation: clinical features, mechanisms, and management. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:1272-1287.e8. https://www.clinicalkey.com. Accessed March 22, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 17 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 16. ClinicalKey. Chan SY, Loscalzo J. Pulmonary arterial hypertension. In: Creager MA, Beckman JA, Loscalzo J. Vascular Medicine: A Companion to Braunwald’s Heart Disease. 3rd ed. Elsevier; 2020:728-756. https://www.clinicalkey.com. Accessed March 22, 2023. 17. ClinicalKey. Curtis AB, Tomaselli GF. Approach to the patient with cardiac arrhythmias. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:1145-1162.e7. https://www.clinicalkey.com. Accessed March 22, 2023. 18. ClinicalKey. Ferguson JD. Management of arrhythmias and device therapy in heart failure. In: Felker GM, Mann DL. Heart Failure: A Companion to Braunwald’s Heart Disease. 4th ed. Elsevier; 2020:549-567. https://www.clinicalkey.com. Accessed March 22, 2023. 19. ClinicalKey. Garan H. Ventricular arrhythmias. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:343-350.e1. https://www.clinicalkey.com. Accessed March 22, 2023. 20. ClinicalKey. Zimetbaum P. Supraventricular cardiac arrhythmias. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:331-343.e4. https://www.clinicalkey.com. Accessed March 22, 2023. 21. ECRI Institute. Clinical Evidence Assessment. Carto 3 system (Biosense Webster, Inc.) for 3-D cardiac mapping in radiofrequency ablation. https://www.ecri.org. Published June 2, 2016. Updated March 25, 2022. Accessed March 9, 2023. 22. ECRI Institute. Clinical Evidence Assessment. Cryoablation versus radiofrequency ablation for treating atrial fibrillation. https://www.ecri.org. Published February 18, 2019. Updated June 3, 2021. Accessed March 9, 2023. 23. ECRI Institute. Clinical Evidence Assessment. Stereotactic body radioablation for treating ventricular tachycardia. https://www.ecri.org. Published July 19, 2022. Accessed March 9, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 18 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 24. ECRI Institute. Clinical Evidence Assessment. Therapeutic intra-vascular ultrasound system (SoniVie) for treating pulmonary arterial hypertension. https://www.ecri.org. Published July 17, 2021. Accessed March 9, 2023. 25. ECRI Institute. Hotline Response. Hybrid cardiac ablation for treating persistent atrial fibrillation. https://www.ecri.org. Published March 16, 2020. Accessed March 9, 2023. 26. ECRI Institute. Product Brief (ARCHIVED). 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Heart Rhythm Society (HRS). 2014 HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. https://www.hrsonline.org. Published May 9, 2014. Accessed April 13, 2023. 33. Heart Rhythm Society (HRS). 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. https://www.hrsonline.org. Published October 2017. Accessed March 29, 2023. 34. Heart Rhythm Society (HRS). 2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRS and LAHRS. https://www.hrsonline.org. Published January 20, 2020. Accessed March 27, 2023. 35. Heart Rhythm Society (HRS). 2019 HRS/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. https://www.hrsonline.org. Published January 2020. Accessed March 27, 2023. 36. Heart Rhythm Society (HRS). 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All legislation/regulations on this subject may not be included. This document is for informational purposes only. Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Effective Date: 05/15/2023 Revision Date: 05/15/2023 Review Date: 04/27/2023 Policy Number: HUM-0581-005 Page: 20 of 23 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 40. Merck Manual: Professional Version. Ablation for cardiac arrhythmia. https://www.merckmanuals.com. Updated January 2023. Accessed March 22, 2023. 41. Merck Manual: Professional Version. Electrophysiologic studies (EPS). https://www.merckmanuals.com. Updated September 2022. Accessed March 22, 2023. 42. UpToDate, Inc. 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Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 67. US Food & Drug Administration (FDA). 510(k) summary: EnSite Precision Cardiac Mapping System. https://www.fda.gov. Published December 13, 2016. Accessed March 22, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.