Catheter Ablation Procedures for Supraventricular Tachyarrhythmias (SVTA)

Coverage decision: Covered with conditions

Conditions of Coverage

  • Injured workers must be adults with supraventricular tachyarrhythmias
    • Reentrant tachycardias (e.g. Wolff-Parkinson-White Syndrome [WPW]), Atrioventricular reentrant tachycardia (AVRT), Atrioventricular nodal reentrant tachycardia (AVNRT)
    • Atrial flutter:
      • Symptomatic atrial flutter
    • Atrial fibrillation:
      • Symptomatic atrial fibrillation
      • Drug therapy is either not tolerated or ineffective
  • The catheter ablation procedures are not covered benefits for other, non-reentrant supraventricular tachycardias.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed catheter ablation procedures for SVTAs on May 17, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that catheter ablation procedures are covered benefits with conditions. Complete information on this HTCC determination is available here: www.hca.wa.gov/hta/Pages/Forms/HTA_Findings.aspx.

Implementation of the Determination

Catheter ablation procedures for SVTAs may be used only for care of a condition accepted on the claim. Temporary authorization may be given to address an unrelated condition that is directly impeding worker’s recovery from their work-related condition. All requests require prior authorization.

For State Fund Claims

Please contact Utilization Review Vendor (Qualis): www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/UtilReview/.

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/.

Billing Codes

CPT Codes: 93650, 93653, 93654, 93655, 93656 and 93657

 

 

Health Care Authority's Health Technology Assessment Program site

For more information:
Contact information.

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