33258
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.73
Facility
$636.29
Non-Facility
$636.29
Documentation Required
- Clinical justification must be provided to indicate when post-operative tests (endocardial catheter electrophysiology study; 24-hour Holter monitor; exercise stress test; color-flow Doppler of transmitral/transtricuspid flow) are 'clinically indicated' if performed, because they are not routinely medically necessary.
- Adequate documentation of the nature and extent of intolerance to antiarrhythmic or other drug therapy when 'cannot tolerate the side effects of drug therapy' is asserted.
- Documentation of prior adequate attempts at medical management when claiming 'hemodynamic consequences of chronic atrial fibrillation/flutter despite adequate attempts at medical management.'
- Documentation supporting high risk for thromboembolism, specifically either: records showing a previous episode of thromboembolism with other sources of emboli ruled out; OR documentation of long-standing atrial fibrillation in members with mitral valve disease who are undergoing open surgical repair of the mitral valve.
Key Coverage Criteria
- Maze procedure, performed with cardiopulmonary bypass on a beating heart, is medically necessary for members with atrial fibrillation or atrial flutter when any of the following criteria is met:
- Member cannot tolerate the side effects of drug therapy (adequate documentation of the nature and extent of the intolerance is required).
- Member is suffering the hemodynamic consequences of chronic atrial fibrillation/flutter despite adequate attempts at medical management.
- Member is at high-risk for thromboembolism as evidenced by either: a previous episode of thromboembolism when other sources of emboli have been ruled out; OR documented long-standing atrial fibrillation in members with mitral valve disease undergoing open surgical repair of the mitral valve.
- Concomitant Maze and septal myectomy is medically necessary for treatment of hypertrophic obstructive cardiomyopathy plus refractory atrial fibrillation/flutter.
- Covered ICD-10 diagnoses (when selection criteria are met): I48.0 (Atrial fibrillation [chronic]), I48.1 (Atrial flutter [chronic]), I42.1 (Obstructive hypertrophic cardiomyopathy).
3 Active Policies
CIGNA-0469 — Atrial Fibrillation: Nonpharmacological Treatments - (0469)
AETNA-CPB-0225 — Maze Procedure
ANTHEM-CG-SURG-05 — CG-SURG-05 Maze Procedure
Related Codes
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