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Medical Policy: 02.02.04
Original Effective Date: October 2004
Reviewed: August 2011
Revised: March 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The underlying mechanism of AF involves interplay between electrical triggering events and the myocardial substrate that permits initiation and maintenance of the aberrant electrical circuit. Recent studies have suggested that triggering foci may be located within the myocytes extending into the pulmonary veins creating a potential target for ablation. Several approaches have emerged: focal ablation within the pulmonary veins, as identified by electrophysiologic mapping, segmental ostial ablation guided by pulmonary vein potential (electrical approach), and circumferential pulmonary vein ablation (anatomic approach). As documented in the peer-reviewed literature circumferential ablation appears to be the preferred approach at the present time.
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Prior Approval:
Not applicable
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Policy:
Transcatheter ablation of arrhythmogenic foci in the pulmonary veins may be considered medically necessary as a treatment of symptomatic paroxysmal atrial fibrillation in the following patients:
- Those who have failed treatment with two antiarrhythmic drugs
- Those with a documented contraindication for antiarrhythmic drugs
- Those with heart failure or left ventricular hypertrophy who have failed treatment with amiodarone or dofetilide and in whom it is essential to maintain rhythm for hemodynamic reasons
Repeat ablations may be considered medically necessary in patients with recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure.
All other indications for pulmonary vein isolation are considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 93799 Unlisted cardiovascular service or procedure. There is no specific CPT code for pulmonary vein isolation.
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Selected References:
- Oral H, Scharf C, Chugh A, et al. Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation. 2003 Nov 11; 108(19):2355-60.
- Thomas SP, Boyd AC, Aggarwal G, et al. Percutaneous pulmonary vein isolation for treatment of atrial fibrillation. Intern Med J 2004 Aug; 34(8):453-7.
- Chen MS, Marrouche NF, Khaykin Y, et al. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol. 2004 Mar 17; 43(6):1004-9.
- Ernst S, Ouyang F, Lober F, et al. Catheter-induced linear lesions in the left atrium in patients with atrial fibrillation: and electroanatomic study. J Am Coll Cardiol. 2003 Oct 1; 42(7):1271-82.
- Schwartzman D, Kanaki H, Bazaz R, Gorcsan J 3rd. Impact of catheter ablation on pulmonary vein morphology and mechanical function. J Cardiovasc Electrophysiol. 2004 Feb; 15(2):161-7.
- American College of Cardiology, American Heart Association, European Society of Cardiology. ACC/AHA/ESC Guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol 2001 Oct;38:1266i-lxx.
- Wazni OM, Marrouche NF, Martin DO et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA. 2005 Jun 1; 293(21):2634-40.
- Chen SA, Hseih MH, Tai CT et al. Initiation of atrial fibrillation by ectopic beats originating form the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation. 1999 Nov 2; 100(18):1879-86.
- Mokadam NA, McCarthy PM, Gillinov AM et al. A prospective multicenter trial of bipolar radiofrequency ablation for atrial fibrillation: early results. Ann Thorac Surg. 2004 Nov; 78(5):1665-70.
- Haissaguerre M, Pierre J, Shah DC et al. Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins. N Engl J Med 1998; 339:659-66.
- Pappone C, Rosanio S, Augello G et al. Mortality, Morbidity, and Quality of Lofe After Circumferential Pulmonary Vein Ablation for Atrial Fibrillation. Outcomes Form a Controlled Nonrandomized Long-Term Study. J Am Coll Cardiol 2003 Jul; 42(2):185-97.
- Noguchi H, Kumagai K, Yasuda T et al. Conduction recovery After Pulmonary Vein Isolation for Atrial Fibrillation. Circ J 2005; 69:65-68.
- Canadian Coordinating Office for Health Technology Assessment (CCOHTA). Radiofrequency Catheter Ablation for Cardiac Arrhythmias: A Clinical and Economic Review. March 2002.
- Thomas SP, Boyd AC, Aggarwal G et al. Percutaneous pulmonary vein isolation for treatment of atrial fibrillation. Internal Med J 2004; 34:453-57.
- Oral H, Pappone C, Chugh A et al. Circumferential Pulmonary-Vein Ablation for Chronic Atrial Fibrillation. N Engl J Med 2006; 354(9):934-41.
- Wood MA, Ellenbogen KA. Catheter Ablation of Chronic Atrial Fibrillation-The Gap between Promise and Practice. N Engl J Med 2006; 354(9):967-69.
- Rosanio S, Ware DL, Saeed M. Pulmonary Vein Ablation of Atrial Fibrillation: Beyond the Traditional. Am J Med Sci 2004; 328(6):323-29.
- Iqbal MB, Taneja AK, Lip GYH, Flather M. Recent Development in Atrial Fibrillation. BMJ 2005; 330:238-43.
- Pappone C, Augello G, Sala S et al. A randomized Trial of Circumferential Pulmonary Vein Ablation versus Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation. The APAF Study. J Am Coll Cardiol 2006;48:2340-7.
- American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Circulation. 2006;114:700-752.
- Forleo GB, Mantica M, DeLuca L et al. Catheter Ablation of Atrial Fibrillation in Patients with Diabetes Mellitus Type 2: Results from a randomized Study Comparing Pulmonary Vein Isolation versus Antiarrhythmic Drug Therapy. J Cardiovasc Electrophysiol. 2008 Sep 3 [Epub ahead of print]
- Markowitz SM. Ablation of atrial fibrillation: patient selection, technique, and outcome. Curr Cardiol Rep. 2008 Sep;10(5):360-6.
- Neumann T, Vogt J, Schumacher B et al. Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. J Am Coll Cardiol. 2008 Jul 22;52(4):273-8.
- Oral H, Chugh A, Yoshida K et al. A randomized assessment of the incremental role of ablation and complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. J Am Coll Cardiol 2009; 53(9):514-21.
- Deisenhofer I, Estner H, Reents T et al. Does electrogram-guided substrate ablation add to the success of pulmonary vein isolation in patients with paroxysmal atrial fibrillation? A prospective, randomized study. J Cardiovasc Electrophysiol 2009; 20(5):514-21.
- Lellouche N, Jais P, Nault I et al. Early recurrences after atrial fibrillation ablation: prognostic value and effect of early reablation. J Cardiovasc Electrophysiol 2008; 19(6):599-605.
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Policy History:
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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