Catheter ablation may be considered medically necessary for the treatment of supraventricular tachyarrhythmias, as follows:
Treatment of paroxysmal supraventricular tachycardia due to AV nodal re-entry tachycardia
Treatment of paroxysmal supraventricular tachycardia due to accessory pathways
Treatment of atrial flutter
Treatment of focal atrial tachycardia
Catheter ablation using radiofrequency energy may be considered medically necessary for the treatment of chronic, recurrent, ventricular tachycardia that is refractory to implantable cardioverter-defibrillator treatment and antiarrhythmic medications, and for which an identifiable arrhythmogenic focus can be identified.
Catheter ablation for ventricular tachycardia “storm” (see Policy Guidelines), may be considered medically necessary when pharmacologic treatment has been unsuccessful in controlling the arrhythmia.
Catheter ablation for all other ventricular arrhythmias is considered investigational.