Medicare AdvantageCoverageHigh impact
Cardiac Electrophysiological Studies and Cardiac Catheter Ablation - Medicare Advantage (Revised)
Humana·Cardiology, Cardiothoracic Surgery, Internal Medicine +1 more·Medicare Advantage
Effective date
Aug 3, 2026
We identified it
Jul 30, 2026
Summary
Humana Medicare Advantage updated its cardiac electrophysiological studies (EPS) and ablation policy effective 08/03/2026, clarifying coverage criteria for diagnostic EPS, atrioventricular node ablation (AVNA), cryoablation/radiofrequency ablation, pulsed field ablation (PFA), and intraoperative EPS. The policy specifies medical necessity requirements for each procedure type, including new guidance on PFA for atrial fibrillation treatment. Billing teams must verify patient eligibility and procedure indications against the defined criteria before claim submission.
Action Required
By 07/31/2026, the billing team must: (1) Update billing system and prior authorization workflows to enforce the specific medical necessity criteria for CPT codes 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93631, 93650, 93653, 93654, and 93656; (2) Create documentation requirements checklist for providers to verify indications are met before submitting claims (e.g., for diagnostic EPS: syncope OR wide complex tachyarrhythmia with inconclusive noninvasive testing; for AVNA: persistent atrial dysrhythmia with rapid ventricular response AND failed/intolerant pharmacological rate control); (3) Notify cardiology and electrophysiology providers of revised coverage criteria, particularly the new PFA coverage for drug-refractory paroxysmal AF and persistent AF with episode duration <1 year; (4) Update claim scrubbing rules to deny or request medical records if procedure indications are not documented per policy. Failure to apply these criteria will result in claim denials and potential overpayment recovery.