Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the MAZE procedure (convergent hybrid ablation) and an
associated inpatient hospital stay.
You asked the Plan to pre-approve MAZE procedure and inpatient level of care. You say that this procedure is
proven to be the most effective for treatment of the enrollee's condition. The Plan denied your request. The
Plan says that the denial of authorization for this service is correct, because studies have not proven that MAZE
is helpful for the enrollee's condition and inpatient level of care is not needed for a non-covered procedure.
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. The rules say that inpatient
hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two
midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital
stay does not cross two midnights or more.
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 MAZE procedure and inpatient level of
care. Our reviewer says that the requested items/services are considered medically reasonable and necessary in
this case. Our physician reviewer found the request is for authorization of the performance--not of the stand-
alone, surgical MAZE procedure--but of the minimally-invasive procedure incorporating epicardial ablation--
performed by a cardiac surgeon--in conjunction with an endocardial catheter ablation procedure--performed by
a cardiac electrophysiologist, often the same day in a combined procedure, or sometimes a few days or weeks
later. The CONVERGE trial (Delugio 2020) demonstrated the superiority of this hybrid approach combining
epicardial and endocardial ablation compared with an endocardial catheter ablation procedure alone. While the
simpler endocardial catheter ablation procedure would be more appropriate for paroxysmal atrial fibrillation,
proceeding directly to a convergent hybrid procedure would be acceptable because of the poor results of
endocardial catheter ablation alone, with the frequent need to later carry out a convergent hybrid procedure. As
a result, authorization for the performance of a convergent hybrid ablation procedure would be considered
appropriate and reasonable in this patient clinical management. It is reasonably expected that the enrollee's
hospital care will span at least 2 midnights; therefore, the enrollee meets criteria for inpatient level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MAZE procedure and inpatient level of care have been met. Therefore, we
decided that the Plan has to pre-approve the MAZE procedure (convergent hybrid ablation) and an associated
inpatient hospital stay.
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.