93583
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
13.41
Facility
$640.96
Non-Facility
$640.96
Documentation Required
- Documentation that member is symptomatic (when applicable) and that symptoms are attributable to the arrhythmia
- Documentation of drug-resistance or drug-intolerance or documentation that the member does not desire long-term drug therapy when these are stated as selection criteria (e.g., for AF, atrial flutter, atrial tachycardia, AVNRT, VT)
- For atrial fibrillation: documentation of evidence of a localized site(s) of origin when ablation is being performed for AF (e.g., documentation supporting pulmonary vein isolation)
- For accessory pathways/WPW: documentation of impact on livelihood/profession/insurability/mental wellbeing/public safety when treating asymptomatic ventricular pre-excitation
Key Coverage Criteria
- VT: members with symptomatic sustained monomorphic VT when the tachycardia is drug-resistant or the member is drug-intolerant or does not desire long-term drug therapy
- Cardiac catheter ablation procedures are medically necessary for atrial tachyarrhythmias in members who meet any of the following: resuscitated from sudden cardiac death due to atrial flutter or atrial fibrillation with a rapid ventricular response in the absence of an accessory pathway
- Atrial tachyarrhythmias: members with a dual-chamber pacemaker and pacemaker-mediated tachycardia that cannot be treated effectively by drugs or by re-programming the pacemaker
- Atrial tachyarrhythmias: members with symptomatic atrial tachyarrhythmias when drugs are not tolerated or the member does not wish to take them, even though the ventricular rate can be controlled
- Atrial tachyarrhythmias: members with symptomatic atrial tachyarrhythmias who have inadequately controlled ventricular rates
- Atrial tachyarrhythmias: members with symptomatic non-paroxysmal junctional tachycardia that is drug-resistant, drugs are not tolerated, or the member does not wish to take them
3 Active Policies
AETNA-CPB-0165 — Cardiac Catheter Ablation and Radioablation
AETNA-CPB-0558 — Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)
ANTHEM-CG-SURG-102 — CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
Related Codes
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