Cardiac Catheter Ablation (CPB 0165, reviewed 2028-08-04)

By 2028-08-04: Billing team must update authorization and adjudication rules in billing software to reflect Aetna's specific medical necessity criteria for cardiac ablation procedures. Create a decision tree or checklist in the system requiring documentation of: (1) arrhythmia type (AF, AVNRT, AT, AFL, accessory pathway, or ventricular arrhythmia), (2) failure/intolerance of medical management where required, and (3) symptom status where applicable. Flag claims for CPT 93650 (AV nodal ablation) to verify member has heart failure with reduced ejection fraction or uncontrolled rapid ventricular response. Flag experimental procedures (e.g., alcohol ablation of vein of Marshall, cardio-neuro-ablation, non-invasive radio-ablation) for automatic denial. Update prior authorization guidelines to distinguish between pulsed field ablation and radiofrequency ablation as medically equivalent alternatives. Educate providers and coders that electrophysiology studies are medically necessary only if no prior study within 3 months. Train billing staff that His-bundle ablation claims must include confirmation of permanent pacemaker placement. Consequences: Claims lacking required medical necessity documentation will be denied; experimental procedure codes will be rejected.