Catheter ablation is a technique to eliminate cardiac arrhythmias by selectively destroying a portion of myocardium or conduction system tissue that contains the arrhythmogenic focus. A variety of energy sources can be used with catheter ablation, such as radiofrequency and/or cryotherapy. Radiofrequency ablation is accomplished under fluoroscopy requiring radiation.
Tachyarrhythmias, defined as abnormal heart rhythms with a ventricular rate of 100 or more beats per minute, are frequently symptomatic and may be life threatening. Signs and symptoms related to the tachyarrhythmia may include shock, hypotension, heart failure, shortness of breath, chest pain, acute myocardial infarction, palpitations, and/or decreased level of consciousness, or death.
Supraventricular tachyarrhythmias are rapid arrhythmias that arise above the level of the ventricles. Paroxysmal supraventricular tachycardia (PSVT) arises from abnormal conduction through the atrioventricular (AV) node or through accessory conduction pathways that bypass the AV node. There are several subtypes of PSVT, the most common being atrioventricular nodal reentry tachycardia (AVNRT). Atrial flutter, a specific type of supraventricular tachyarrhythmia, is characterized by regular atrial depolarizations of approximately 300 beats/min. Focal atrial tachycardia usually arises from an abnormal automatic focus or micro-reentry circuits in the right atrium.
Ventricular tachycardia (VT) most commonly occurs in the setting of underlying structural heart disease. VT is usually precipitated by scar tissue in the left ventricle from either a previous myocardial infarction (MI) or from fibrosis of the myocardium that occurs from a cardiomyopathy. Less frequently, certain genetic syndromes (e.g. Brugada syndrome) are associated with ventricular tachyarrhythmias.
Incessant VT, or “ventricular tachycardia storm” refers to tachycardia that occurs more than 3 times in a 24-hour period, often in association with an acute cardiac event such as a MI. VT storm is potentially life-threatening and requires rapid treatment and control.
Cardiac catheter ablation is invasive in that a catheter is passed into the heart via an arm or leg vein and complications may occur. Reported adverse events include vascular injury, perforation of the heart muscle, myocardial infarction (MI), thromboembolism leading to a stroke or transient ischemic attach (TIA), heart failure, and radiation exposure.
NOTE: See policy II-95 for information on catheter ablation for the treatment of atrial fibrillation.
I. Supraventricular Tachyarrhythmia
Catheter ablation may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of supraventricular tachyarrhythmias, due to ANY of the following:
II. Ventricular Tachycardia
Catheter ablation may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of chronic, recurrent, ventricular tachycardia when ALL of the following criteria are met:
III. Ventricular Tachycardia Storm
Catheter ablation for ventricular tachycardia storm may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
IV. Catheter ablation for all other tachyarrhythmias is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of clinical evidence demonstrating an impact on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.