Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an electrophysiologic study with Atrial Ablation. 
 
You asked the Plan to pre-approve Comprehensive electrophysiologic evaluation including insertion and 
repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right 
atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording 
(when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of 
supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular 
connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry (93653) and 
Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from 
multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) 
(93609). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says that the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Comprehensive electrophysiologic 
evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted 
induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when 
necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic 
focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, 
accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-
entry (93653) and Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation 
to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary 
procedure) (93609). Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the decision as to whether to maintain medical therapy for 
rhythm stability vs ablation is an individualized one based on specific clinical situations, patient preferences 
and risk/benefits of continued long-term medical therapy which can have proarrhythmic affects. Ablation in 
lieu of medical therapy is given a IIa indication within current American College of Cardiology/Heart Rhythm 
Society guidelines based on the specific clinical situation (1). This is an even more compelling argument as 
atrial flutter is more easily ablated than atrial fibrillation with generally less risk.  As such, based on the CMS 
criteria of reasonableness and medical necessity (section 1862), and based on clinical guidelines, atrial flutter 
ablation is medically reasonable and appropriate in this instance and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Comprehensive electrophysiologic evaluation including insertion and 
repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right 
atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording 
(when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of 
supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular 
connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry (93653) and 
Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from 
multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) 
(93609) have been met. Therefore, we decided that the Plan has to pre-approve an electrophysiologic study 
with Atrial Ablation.