Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a surgical endoscopic heart procedure (CPT 33266 - operative tissue ablation and extensive reconstruction of atria without cardiopulmonary bypass).Findings:  Two of the three physician reviewers found the requested surgical endoscopic heart procedure (CPT 33266 - operative tissue ablation and extensive reconstruction of atria without cardiopulmonary bypass) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. A hybrid procedure of minimally invasive surgery and combined electrophysiology (EP) mapping and ablation for atrial fibrillation may overcome the shortcomings of each technique individually. With this technique, surgical ablation is performed through a minithoracotomy with concomitant EP mapping to confirm conduction block, and surgical and percutaneous ablations are performed to complete the block as necessary. There are several advantages of a hybrid procedure, including an EP to confirm conduction block, a maximal anterior and posterior approach to maximize efficacy and outcomes, and a minimization of potential surgical and catheter-based complications. Current medical literature supports the use of these techniques. Boersma and colleagues report that catheter ablation and minimally invasive surgical ablation have become accepted therapy for antiarrhythmic drug-refractory atrial fibrillation, and that in atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation catheter ablation, surgical ablation was superior to catheter ablation in achieving freedom from left atrial arrhythmias after 12 months of follow-up. Krul and colleagues note that EP guided thorough pulmonary vein isolation and additional left atrial ablation line creation may contribute to achieving a high success rate in the surgical treatment of atrial fibrillation. DeLurgio and colleagues noted an overall success of a Convergent hybrid procedure to endocardial catheter ablation for the treatment of persistent and longstanding persistent atrial fibrillation. In this clinical setting, the requested service is superior to standard therapy in treating the patient. Therefore, a surgical endoscopic heart procedure (CPT 33266 - operative tissue ablation and extensive reconstruction of atria without cardiopulmonary bypass) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in interventional cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.