Intracardiac Electrophysiologic Studies
DESCRIPTION
Intracardiac electrophysiologic studies involve the placement of multiple catheter electrodes into the heart for the diagnosis and management of selected cardiac conditions. These procedures have been used mainly for identifying the mechanisms, site, and severity of bradycardia or tachyarrhythmias.
The general categories of intracardiac electrophysiologic studies are:
Programmed stimulation techniques to assess the function of the sinoatrial (SA) node and the atrioventricular (AV) conduction system;
Programmed stimulation techniques to induce and terminate supraventricular and ventricular arrhythmias; and
Mapping techniques to determine tachycardia pathways
POLICY
Intracardiac electrophysiologic studies, for ventricular fibrillation or recurrent sustained tachycardia, without history of a recent myocardial infarction, or other severe symptomatic arrhythmias for which non-invasive studies were inconclusive, are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Intracardiac electrophysiologic studies, for ventricular fibrillation or recurrent sustained tachycardia, without history of a recent myocardial infarction, or other severe symptomatic arrhythmias for which non-invasive studies were inconclusive, are considered medically appropriate for ANY ONE of the following conditions:
Supraventricular tachycardia (e.g., Wolfe-Parkinson-White syndrome, atrial flutter, and atrial fibrillation)
Unexplained recurrent syncope
Ventricular tachycardia and ventricular fibrillation
Intraventricular conduction delay
Sinus node dysfunction.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American College of Cardiology. (1995). ACC/AHA Practice Guidelines: Clinical intracardiac electrophysiological and catheter ablation procedures. Retrieved October 21, 2009 from http://www.besancon-cardio.org/recommandations/elec_abla.htm.
American College of Cardiology. (2006). Task Force 6: Training in specialized electrophysiology, cardiac pacing, and arrhythmia management. Journal of the American College of Cardiology, 47 (4), 904-910.
American College of Cardiology. American Heart Association. (2006). Update of the clinical competence statement on invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on clinical competency and training developed in collaboration with the Heart Rhythm Society. Journal of the American College of Cardiology, 48 (7), 1503-1517.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Intracardiac Electrophysiologic Studies (2.02.05). Retrieved October 21, 2009 from BlueWeb.
Burkhardt, J.D. & Wilkoff, B.L. (2007). Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure. Circulation, 115(16), 2208-2220.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Diagnostic endocardial electrical stimulation (pacing) (NCD 20.12, p. 2-19). The Ingenix Complete Guide to Medicare Coverage Issues.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Intraoperative ventricular mapping (NCD 20.11, p. 2-19). The Ingenix Complete Guide to Medicare Coverage Issues.
Lindsay, B. D., Kutalek, S. P., Cannom, D. S., Hammill, S. C., & Naccarelli, G. V. (2001). Reprocessing of electrophysiology catheters: Clinical studies, regulations, and recommendations. Journal of Pacing and Clinical Electrophysiology. 24 (8), 1297-1305.
Miller, T. H., & Kruse, J. E. (2005). Evaluation of syncope. American Family Physician, 72 (8), 1492-1500.
Saremi, F., & Krishnan, S. (2007). Cardiac conduction system: anatomic landmarks relevant to interventional electrophysiologic techniques demonstrated with 64- detector CT. RadioGraphics, 27, (6), 1539-1566.
U. S. Food and Drug Administration (2002, August). Center for Devices and Radiological Health. 510 (K) Summary. Retrieved October 21, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf/K012678.pdf.
U. S. Food and Drug Administration. (2005, June). Center for Devices and Radiological Health. 510(K) Summary. Retrieved October 21, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051220.pdf.
U. S. Food and Drug Administration. (2007, May). Center for Devices and Radiological Health. 510(K) Summary. Retrieved October 21, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K070242.pdf.
ORIGINAL EFFECTIVE DATE: 8/1985
MOST RECENT REVIEW DATE: 11/12/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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