CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation

This policy addresses cardiac electrophysiological studies (EPS) and intracardiac catheter ablation for diagnosing and treating cardiac arrhythmias. These services are covered as medically necessary when plan criteria are met—examples include EPS for evaluation of syncope in patients with ischemic or structural heart disease with impaired LV function (LVEF ≤35%), risk stratification after myocardial infarction with preserved LV function (LVEF >35%), suspected sick sinus syndrome, or when brady- or tachyarrhythmias are suspected causes of symptoms; ablation may be performed when indicated based on EPS findings. They are not covered when criteria are not met and for other uses such as risk stratification for sudden cardiac death in hypertrophic cardiomyopathy or conditions not specified in the policy.

"Cardiac electrophysiological procedures and studies may include the following when criteria are met (A and B):"