Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve open and thoracoscopic approaches to treat atrial fibrillation or 
atrial flutter (Maze and related procedures (CPT code(s): 33266, 32650, and 93318), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that there have been two (2) unsuccessful procedures 
performed last year and this is procedure is medically necessary in order to treat the enrollee's atrial fibrillation. 
You state the entire treatment team has recommended that this procedure is medically necessary and failure to 
approve this treatment means shortness of breath, inability to exercise, swelling and weight gain will remain 
unresolved and continue to detrimentally impact the enrollee's health, well-being and quality of life. The Plan 
denied your request. The Plan says that open and thoracoscopic approaches to treat atrial fibrillation or atrial 
flutter (Maze and related procedures), standalone Maze procedure (defined as a combined percutaneous 
(through the skin) and thoracoscopic (through the chest) approach) is considered investigational for the 
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 pre-approve the services. 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 (Delrugio 2020) demonstrated the superiority of this hybrid approach combining epicardial 
and endocardial ablation compared with an endocardial catheter ablation procedure alone. In this enrollee, the 
endocardial catheter ablation procedure was unsuccessful. As a result, authorization for the performance of a 
convergent hybrid ablation procedure would be considered appropriate and reasonable in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve open and thoracoscopic approaches to treat atrial fibrillation or atrial flutter (Maze and related 
procedures (CPT code(s): 33266, 32650, and 93318), for the enrollee.  
 
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.