C1889 — Implantable/insertable device, not otherwise classified
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For catheter ablation: documentation of symptomatic atrial fibrillation (paroxysmal or persistent) and that antiarrhythmic drugs have been ineffective, contraindicated, not tolerated or not preferred.
- For catheter ablation in HFrEF: documentation of heart failure with reduced ejection fraction (HFrEF) with ejection fraction ≤ 40%.
- For athlete indication: documentation supporting high-volume endurance athleticism defined as exercise of >45 metabolic equivalent-hours per week.
- For pulmonary hypertension indication: documentation of pulmonary hypertension (PH) with pulmonary vascular disease and atrial fibrillation.
Key Coverage Criteria
- Cardiac catheter ablation with pulmonary vein isolation (Current Procedural Terminology [CPT®] codes 93656, 93657) is considered medically necessary for ANY of the following indications:
- Symptomatic atrial fibrillation (paroxysmal or persistent) AND antiarrhythmic drugs have been ineffective, contraindicated, not tolerated or not preferred
- Symptomatic atrial fibrillation (e.g., palpitations, chest pain, dyspnea) associated with heart failure and reduced ejection fraction (HFrEF) of ≤ 40%
- An athlete* who develops atrial fibrillation with or without symptoms *high-volume endurance athleticism, defined as exercise of >45 metabolic equivalent-hours per week
- Individual with or without symptoms with pulmonary hypertension (PH) with pulmonary vascular disease and atrial fibrillation
- Repeat cardiac catheter ablation is considered medically necessary for an individual with recurrent symptomatic atrial fibrillation (American College of Cardiology Class 1 recommendation).
6 Active Policies
CIGNA-0469 — Atrial Fibrillation: Nonpharmacological Treatments - (0469)
BCBSIL-SUR705.045 — Annulus Closure After Discectomy
BCBSMT-SUR705.045 — Annulus Closure After Discectomy
BCBSNM-SUR705.045 — Annulus Closure After Discectomy
BCBSOK-SUR705.045 — Annulus Closure After Discectomy
Related Codes
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