93622
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Patient age documented (must be >= 18 years for coverage under this policy).
- Clinical documentation of the specific arrhythmia diagnosis (e.g., AVRT, preexcited AF, CTI-dependent atrial flutter, non-CTI atrial flutter, AVNRT, focal AT, junctional tachycardia, PVCs, ventricular tachycardia/fibrillation).
- Electrocardiographic evidence and/or EP study documentation confirming arrhythmia mechanism and localization (EP study reports, intracardiac recordings, inducibility, mapping data).
- For accessory pathway ablation: documentation of EP study findings including any 'high-risk' characteristics identified on EP testing (when applicable).
Key Coverage Criteria
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: accessory pathway ablation in individuals with atrioventricular reentrant tachycardia (AVRT), preexcited atrial fibrillation (AF), or high-risk findings on an electrophysiological (EP) study.
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: cavotricuspid isthmus (CTI)-dependent atrial flutter.
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: CTI-dependent atrial flutter induced at the time of AF ablation.
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: recurrent symptomatic non-CTI-dependent atrial flutter.
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: symptomatic atrioventricular nodal reentrant tachycardia (AVNRT).
- Transcatheter ablation of supraventricular tachycardia (CPT 93653) is medically necessary in adults (>= 18 years) for: symptomatic focal atrial tachycardia (AT) as an alternative to pharmacological therapy.
4 Active Policies
CARELON-electrophysiological-studies-2024-07-01 — Electrophysiological Studies
CIGNA-0529-FUTURE — Cardiac Ablation of Abnormal Electrical Rhythms in Adults - (0529)
HUMANA-CARDIAC-ELECTROPHYSIOLOGICAL-STUDIES-AND-CARDIAC-CATHETER-ABLATION-MA — Cardiac Electrophysiological Studies and Cardiac Catheter Ablation - Medicare Advantage
ANTHEM-CG-SURG-55 — CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
Related Codes
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