Abbott Catheter Ablation for Atrial Fibrillation Instructions

Abbott Catheter Ablation for Atrial Fibrillation

Instructions

Instructions for completing the sample letter of medical necessity:

1. Please customize the prior authorization template based on the medical appropriateness of catheter ablation for atrial fibrillation for your patient. Fields required for customization are highlighted in yellow.
2. It is important to provide the most complete information to assist with the prior authorization process.
3. After you have customized the medical necessity letter, please make sure to delete any specific instructions for completion that are highlighted throughout the letter, so the health plan does not misinterpret the information.

Disclaimer

This document and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal reimbursement, business, clinical or other advice. Furthermore, it does not constitute a representation or guarantee of reimbursement, and it is not intended to increase or maximize payment by any payer. Nothing in this document should be construed as a guarantee by Abbott regarding reimbursement or payment amounts, or that reimbursement or other payment will be received. The ultimate responsibility for obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently, and, therefore, the customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial or reimbursement specialist for any questions related to billing, reimbursement or any related issue. This information does not guarantee coverage or payment at any specific level, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.

Date] [Payer contact name] [Payer contact title] [Payer] [Street address] [City, State, zip code]

Re: Request for Prior Authorization of Medical Services for Catheter Ablation for Atrial Fibrillation

Patient name: [First and last name] Patient date of birth: [XX/XX/XXXX] SS # [XXX-XX-XXXX] Insurance ID # [XXXXXXXXXXXXXXX] Group # [XXXXXXXXXX] Date of Service: [XX/XX/XXXX]

Dear [Payer contact name]:
I am writing to request a prior authorization of coverage for catheter ablation for atrial fibrillation (AF) on behalf of my patient, [Patient Name]. Catheter ablation for atrial fibrillation is supported by medical care guidelines in the United Healthcare (UHC) MCG™ Care Guidelines for Electrophysiologic Study and Intracardiac Catheter Ablation ORG: M-154 (ISC). Physicians perform catheter ablations with the goal of reducing the patient’s symptoms associated with atrial fibrillation. The service provided is catheter ablation in an [inpatient / outpatient] setting at [facility name] provided to [patient’s name] scheduled for [procedure date].

Background

Catheter ablation for atrial fibrillation procedures involves the insertion of one or more catheters through blood vessels into the patient’s heart. Dye may be injected into the catheter, to help visualize the patient’s blood vessels and heart using X-ray imaging. The catheters have electrodes at the tips that can be used to send electrical impulses to the heart and record the heart’s electrical activity. Mapping catheters may be used to determine where the abnormal triggers are located. Ablation catheters are then used to deliver extreme heat via radio frequency or cold with the catheter tips to destroy (ablate) these spots. This process causes scarring that disrupts the faulty electrical signals and restores normal heart rhythms. This scar forms a barrier that prevents electrical impulses from crossing between the damaged heart tissue to the surrounding healthy tissue. This will stop abnormal electrical signals from traveling to the rest of the heart and causing arrhythmias.
Patients with atrial fibrillation have a significantly poorer quality of life compared to healthy patients, the general population, and patients with another cardiovascular disease. Although stroke prevention is an important goal of AF treatment, minimizing symptoms, physical limitations, and the negative impact AF has on quality-of-life is tantamount for patients. Recent data has also highlighted the strong link between AF burden and the development on heart failure over time, another highly morbid condition. Although AF is associated with increased mortality, the absolute risk elevation of death in contemporary populations is low, thus mortality reduction is not the primary goal of therapy. The goal is to improve quality of life and prevent the subsequent development of comorbidities, such as heart failure, stroke, and dementia, that might eventually over time result in death.

Medical Necessity

Because your health plan requires prior authorization for catheter ablation for atrial fibrillation, I am specifically requesting that this procedure is covered based on my patient meeting the FDA-approved labeling and the MCG™ Care Guidelines: Electrophysiologic Study and Intracardiac Catheter Ablation ORG: M-154 (ISC). My patient is an appropriate candidate for cardiac ablation for atrial fibrillation because [briefly summarize the patient’s clinical history, treatments tried and failed, and benefit of cardiac ablation].

In summary, my patient is an appropriate candidate for catheter ablation for atrial fibrillation based on the criteria provided by your health plan. [Please provide summary after reviewing the UHC prior authorization policy for cardiac ablation for Atrial Fibrillation and the MCG Care Guidelines referenced.]

We are requesting confirmation that this therapy be considered a covered benefit based on medical necessity and that associated professional fees for the surgery and follow-up will be covered. I request authorization for all costs associated with the catheter ablation, including physician professional fees and facility fees. The charge for the catheters and supplies are included in the facility fees. The catheter ablation procedure will be scheduled at [Name of the clinic or facility].The procedure codes supporting the implant consist of the following:

Atrial Fibrillation: ICD-10 Diagnosis(es) [] [] [__]

Physician Procedure Codes

93656

| Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary, and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein

isolation

| ****

1

+93657

| Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List

separately in addition to code for primary procedure)

| [input value as

appropriate]

Facility Procedure Codes

93656

| Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary, and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by

pulmonary vein isolation

| ****

1

+93657

| Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)| [input value as      appropriate]

I have attached relevant excerpts from the patient’s medical record including relevant history and physical to include member symptoms and pertinent findings, signs and symptoms, treatments tried and failed, and results of diagnostic testing. I believe that catheter ablation for atrial fibrillation is medically reasonable and necessary and warrants prior authorization of coverage and payment for these services.
Please let me know if I can provide any additional information and thank you for your attention.
Sincerely,
[Physician’s name and credentials] [Title] [Name of practice] [Street address] [City, State, zip code] [Phone number]

Enclosures:
[Patient medical records/chart notes]

Appendix

Additional clinical data demonstrating the safety and effectiveness of Catheter Ablation for Atrial Fibrillation Resources

The published clinical data on the safety and effectiveness of catheter ablation for atrial fibrillation include but are not limited to the following:
Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ and Yamane T. 2017

HRS/EHRA/ECAS/APHRS/SOLACE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14:e275e444.
Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, Merkely B, Pokushalov E, Sanders P, Proff J, Schunkert H, Christ H, Vogt J, Bansch D and Investigators C-A. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018;378:417-427.
Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, Noseworthy PA, Rosenberg YD, Jeffries N, Mitchell LB, Flaker GC, Pokushalov E, Romanov A, Bunch TJ, Noelker G, Ardashev A, Revishvili A, Wilber DJ, Cappato R, Kuck KH, Hindricks G, Davies DW, Kowey PR, Naccarelli GV, Reiffel JA, Piccini JP, Silverstein AP, Al-Khalidi HR, Lee KL and Investigators C. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019;321:1261-1274.

Pappone C, Vicedomini G, Augello G, Manguso F, Saviano M, Baldi M, Petretta A, Giannelli L, Calovic Z, Guluta V, Tavazzi L and Santinelli V. Radiofrequency catheter ablation and antiarrhythmic drug therapy: a prospective, randomized, 4-year follow-up trial: the APAF study. Circ Arrhythm Electrophysiol. 2011;4:808-14.
Poole JE, Bahnson TD, Monahan KH, Johnson G, Rostami H, Silverstein AP, Al- Khalidi HR, Rosenberg Y, Mark DB, Lee KL, Packer DL, Investigators C and Lab ECGRC. Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial. J Am Coll Cardiol. 2020;75:3105-3118.
Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Saliba W, Bash D, Schweikert R, Brachmann J, Gunther J, Gutleben K, Pisano E, Potenza D, Fanelli R, Raviele A, Themistoclakis S, Rossillo A, Bonso A and Natale A. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA.
2005;293:2634-40.

Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A, Macle L, Daoud EG, Calkins H, Hall B, Reddy V, Augello G, Reynolds MR, Vinekar C, Liu CY, Berry SM, Berry DA and ThermoCool AFTI. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303:333-40.

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