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DESCRIPTIONAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence estimated at 0.4% of the population, increasing with age. The underlying mechanism of AF involves an interplay between electrical triggering events and the myocardial substrate that permits propagation and maintenance of the aberrant electrical circuit. The most common focal trigger of AF appears to be located within the cardiac muscle that extends into the pulmonary veins.
AF accounts for approximately one third of hospitalizations for cardiac rhythm disturbances. Symptoms of AF, i.e., palpitations, decreased exercise tolerance, and dyspnea, are primarily related to poorly controlled or irregular heart rate. The loss of atrioventricular (AV) synchrony results in a decreased cardiac output, which can be significant in patients with compromised cardiac function. In addition, patients with AF are at higher risk for stroke, and anticoagulation is typically recommended. AF is also associated with other cardiac conditions, such as valvular heart disease, heart failure, hypertension, and diabetes. Although episodes of AF can be converted to normal sinus rhythm using either pharmacologic or electroshock conversion, the natural history of AF is one of recurrence, thought to be related to fibrillation-induced anatomic and electrical remodeling of the atria
AF can be subdivided into paroxysmal (episodes that last fewer than 7 days and are self-terminating), persistent (episodes that last for more than 7 days and can be terminated pharmacologically or by electrical cardioversion) or permanent. Treatment strategies can be broadly subdivided into rate control, in which only the ventricular rate is controlled and the atria are allowed to fibrillate, or rhythm control, in which there is an attempt to reestablish and maintain normal sinus rhythm. Rhythm control has long been considered an important treatment goal for management of AF, although its primacy has recently been challenged by the results of several randomized trials that reported that pharmacologically maintained rhythm control offered no improvement in mortality or cardiovascular morbidity compared to rate control.
Currently, the main indications for a rhythm control are for patients with paroxysmal or persistent AF who have hemodynamic compromise associated with episodes of AF or who have bothersome symptoms despite adequate rate control. A rhythm control strategy involves initial pharmacologic or electronic cardioversion, followed by pharmacologic treatment to maintain normal sinus rhythm. However, antiarrhythmic medications are often not effective in maintaining sinus rhythm. As a result, episodes of recurrent AF are typical, and patients with persistent AF may require multiple episodes of cardioversion. Implantable atrial defibrillators, which are designed to detect and terminate an episode of AF, may be an alternative in patients otherwise requiring serial cardioversions, but these have not yet achieved widespread use. Patients with paroxysmal AF, by definition, do not require cardioversion, but may be treated pharmacologically to prevent further arrhythmic episodes.
Treatment of permanent AF focuses on rate control, using either pharmacologic therapy or ablation of the AV node followed by ventricular pacing. Although AV nodal ablation produces symptomatic improvement, it does entail lifelong anticoagulation (due to the ongoing fibrillation of the atria), loss of AV synchrony, and lifelong pacemaker dependency. Implantable defibrillators are contraindicated in patients with permanent AF.
The above treatment options are not considered curative. A variety of ablative procedures have been investigated as potentially curative approaches, or perhaps modifying the arrhythmia such that drug therapy becomes more effective. Ablative approaches focus on interruption of the electrical pathways that contribute to AF, through modifying triggers of AF and/or the myocardial substrate that maintains the aberrant rhythm. The Maze procedure, an open surgical procedure often combined with other cardiac surgeries (i.e., valve repair), is an ablative procedure involving sequential atriotomy incisions designed to create electrical barriers that prevent the maintenance of AF.
Radiofrequency ablation using a percutaneous catheter-based approach is a widely used technique for a variety of Supraventricular arrhythmias, in which intracardiac mapping identifies a discrete arrhythmogenic focus. Since the inception of ablation techniques in the early 1990s, there has been a progressive understanding of the underlying electrical pathways in the heart that are associated with AF. In the late 1990s, it was recognized that AF most frequently arose from an abnormal focus at or near the junction of the pulmonary veins and the left atrium, thus leading to the feasibility of more focused, percutaneous ablation techniques.
The basic strategies that have emerged for focal ablation within the pulmonary veins, as identified by electrophysiologic mapping, are segmental ostial ablation guided by pulmonary vein potential (electrical approach), or circumferential pulmonary vein ablation (anatomic approach). Circumferential pulmonary vein ablation is the most commonly used approach at the present time.
Transcatheter radiofrequency ablation of arrhythmogenic foci in the pulmonary veins may be considered medically necessary as a treatment for either of the following indications which have failed to respond to adequate trials of antiarrhythmic medications:
Repeat radiofrequency ablations may be considered medically necessary in patients with recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure.
Transcatheter ablation of arrhythmogenic foci in the pulmonary veins is considered investigational as a treatment for all indications except for specific cases of atrial fibrillation as noted above.
Transcatheter cryoablation of arrhythmogenic foci in the pulmonary veins as a treatment for atrial fibrillation is considered investigational.
POLICY GUIDELINESThe coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY7/27/2006: Approved by Medical Policy Advisory Committee (MPAC)
8/3/2007: Policy reviewed, no changes
9/24/2009: Policy statement section updated to include indications which may be considered medically necessary. Code reference section updated to add diagnosis codes 427.31 and 428.0.
10/14/2010: Annual ICD-9 code update: Revised the description of ICD-9 procedure code 37.34.
12/30/2010: New policy statement added to indicate that transcatheter cryoablation of the pulmonary veins as a treatment for atrial fibrillation is considered investigational.
06/08/2011: Policy statements revised for clarity; intent unchanged. Added policy statement regarding repeat procedures.
04/19/2012: Policy title changed from "Pulmonary Vein Isolation and Ablation as a Treatment of Atrial Fibrillation" to "Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation." Policy statement unchanged.
03/08/2013: Added the following new 2013 CPT codes to the Code Reference section: 93656 and 93657. Since new specific CPT codes are available, added note to CPT code 93651 to indicate that this code should only be used for procedures performed prior to 01/01/2013. Added ICD-9 code 427.32 to the Code Reference section.
08/07/2013: Policy reviewed; no changes to policy statement. Added ICD-9 code 427.0 to Code Reference section.
SOURCE(S)Blue Cross Blue Shield Association Policy # 2.02.19
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.