93657
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.36
Facility
$260.86
Non-Facility
$260.86
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
- Refer to the protocol titled Medical Records Documentation Used for Reviews.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan.
- Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates.
Key Coverage Criteria
- Catheter ablation for atrial fibrillation is proven and medically necessary in certain circumstances.
- For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Electrophysiology (EP) Testing +/- Radiofrequency Ablation (RFA) or Cryothermal Ablation, Cardiac.
- This Medical Policy applies to UnitedHealthcare Commercial benefit plans.
- This Medical Policy applies to Individual Exchange benefit plans.
- Note: This policy does not apply to members ages < 18 years or to arrhythmias other than atrial fibrillation.
- Cardiac catheter ablation with pulmonary vein isolation (Current Procedural Terminology [CPT®] codes 93656, 93657) is considered medically necessary for ANY of the following indications:
5 Active Policies
CARELON-transcatheter-ablation-for-management-of-atrial-fibrillation-2024-07-01-r0125 — Transcatheter Ablation for Management of Atrial Fibrillation
UMR-POL-UMR-catheter-ablation-atrial-fibrillation — Catheter Ablation for Atrial Fibrillation
SUREST-POL-SUREST-catheter-ablation-atrial-fibrillation — Catheter Ablation for Atrial Fibrillation
CIGNA-0469 — Atrial Fibrillation: Nonpharmacological Treatments - (0469)
Related Codes
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