Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient admission for the Maze procedure provided from
March 30, 2021, through April 8, 2021.

You asked the Plan to pay for an inpatient admission for the Maze procedure. You say that the inpatient admission for the Maze procedure is medically necessary. The Plan denied your request. The Plan says that based upon the Plan's criteria and review of the peer-reviewed literature, minimally invasive, off-pump, Maze procedures (e.g., mini thoracotomy), including hybrid or convergent ablation procedures (catheter and surgical ablation), are considered investigational as a treatment of atrial fibrillation or flutter.

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 pay for an inpatient admission for the Maze procedure. Our reviewer says that the inpatient admission for the Maze procedure is considered medically reasonable and necessary in this case. Our physician reviewer found that at issue is whether minimally invasive, off-pump, Maze procedures (e.g., mini thoracotomy), including hybrid or convergent ablation procedures (catheter and surgical ablation) for the enrollee is a covered service under Medicare rules. In the absence of a local or national coverage determination, the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), defines medically necessary and reasonable services. UptoDate states that: The convergent procedure is a subxiphoid approach that requires both surgery and catheter ablation in a single hospitalization to complete. Long-term follow-up is needed. Both the right and bilateral thoracoscopic approaches allow for a staged or concomitant approach. The right thoracotomy uses unipolar suction-assisted radiofrequency ablation. The bilateral uses bipolar radiofrequency ablation clamps and is the only approach that allows for treatment of the left atrial appendage. Although initially a simultaneous or single-stage approach predominated, there has been a trend toward a staged approach, performing the electrophysiology portion only in the patients that fail initial surgery. In a small single center series, the staged, bilateral approach has been demonstrated to be as efficacious as a "cut-and-sew" open Maze, but none of the reports is large enough to make definitive recommendations for any of these procedures. However, they do offer the potential for improving the success of treatment in challenging patients without the full extent of surgery or its complications. They may be considered in medically refractory atrial fibrillation patients who are unlikely to be successfully treated with catheter ablation alone. 

In this case, the record indicates that the enrollee has persistent symptomatic atrial fibrillation and has failed pharmacologic and traditional ablation. The enrollee has medically refractory atrial fibrillation that is unlikely to be successfully treated with catheter ablation alone.

The documentation provided supports the medical necessity and reasonableness of the requested procedure in this clinical scenario. The elements of the coverage rule are satisfied. The requested service is recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission for the Maze procedure have been met. Therefore, we decided that the Plan has to pay for an inpatient admission for the Maze procedure provided from March 30, 2021, through April 8, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.