Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an endoscopy, surgical; operative tissue ablation and 
reconstruction of atria, extensive (e.g., maze procedure), without cardiopulmonary bypass (33266). 
 
You asked the Plan to pre-approve a maze procedure. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says that they do not cover a minimally 
invasive off-pump Maze procedure including a hybrid or convergent ablation procedure for any indication 
including the treatment of atrial fibrillation because each is considered experimental, investigational, or 
unproven. 
 
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 an endoscopy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the appropriateness and medical necessity of performing a convergent hybrid 
ablation procedure in an enrollee with persistent atrial fibrillation despite previous endocardial catheter ablation 
procedure. 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. In this enrollee, the endocardial catheter 
ablation procedure was unsuccessful. The surgical Maze procedure with cardiopulmonary bypass would be a 
more invasive procedure particularly in this enrollee with severely depressed left ventricular function. 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 an endoscopy have been met. Therefore, we decided that the Plan has to pre-
approve an endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (e.g., maze 
procedure), without cardiopulmonary bypass (33266).  
 
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.