Pulmonary Vein Isolation for the Management of Atrial Fibrillation  Printer-Friendly Version
Medical Policy: 02.02.04
Original Effective Date: October 2004
Reviewed: September 2008
Revised: March 2007
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
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
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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- CPT 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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