Blue Cross Blue Shield Calls Atrial Fibrillation Ablation Investigational And Denies Coverage!!

Kansas City, January 7, 2008

BlueCross BlueShield of Kansas City has sent several of its insurance holders a notification saying that Atrial Fibrillation ablation is no longer a covered benefit in their insurance program. The letter sent out by Bluecross Blueshield quotes – “ It has come to our attention that we may have paid for a procedure called Pulmonary vein isolation for you in the past six months that is considered ‘investigational’ according to our corporate medical policy. Pulmonary vein isolation is used to treat atrial fibrillation. Because the effectiveness of this service has not been established, it is our policy to not cover it for our members.” The notification went on to say that the above mentioned policy was effective May 1, 2008.

The underlying circumstances that prompted this major health insurance company to take this action were unclear. Pulmonary vein isolation otherwise known as the AF ablation is one of the most extraordinary advancement that the field of electrophysiology has made in the last decade. Discovery of pulmonary veins as the major contributors to the initiation of atrial fibrillation has led to this landmark procedure that changed the way physicians treated patients with this disabling heart rhythm condition. This heart rhythm condition affects at least 4-5 % population and its incidence increases significantly with ageing. Pulmonary vein isolation in combination with ablation of the other areas of the atria (upper chambers of the heart) has proven to be very successful in abating AF anywhere from 60 - 90% of patients depending on their underlying conditions. This procedure has been recognized as standard of care in eligible patients by the worlds leading cardiovascular societies including – The American Heart Association, American Cardiology of Cardiology, Heart Rhythm Society and European Society of Cardiology.

Currently the Center for Medicare Services (CMS) currently covers this particular procedure. Since the initial experience of pulmonary vein isolation by Michel Haissaguerre’s group from Bordeaux, France in the New England Journal of Medicine article in 1998, more than 1400 articles have been published in major peer reviewed journals. This is the most well studied subject than any other heart rhythm condition known to the medical field. AF ablation has changed the lives of millions of people around the world who would have otherwise been left on warfarin and heart rate/rhytm control medications for the rest of their lives. The one time upfront costs of this procedure are definitely higher than a single electrical cardioversion (external shock) with drug therapy. The cumulative costs of treating this arrhythmia with conventional lifelong drug therapy including all the patient visits to the emergency rooms, urgent cares, electrical cardioversions, blood tests, echocardiographic tests and hospitalizations were proven to be significantly higher than AF ablation. The devastating effects of stroke and heart failure (from tachycardia mediated cardiomyopathy) are worth taking into account in these patients. There are several published reports that support the superiority of AF ablation over drug therapy from an economic stand point.

Obviously, this latest move by BlueCross BlueShield may save them millions of dollars but denies hundreds of eligible patients their fundamental right to appropriate treatment. Unilateral decisions by insurance companies to deny particular tests and procedures have occurred in the past and AF ablation is a new addition to the list. Situations like this clearly challenge the value and credibility of clinical guidelines put out by the scientific organizations.

Atrial Fibrillation: a Patient’s Guide to Understanding Drug Therapy

Citation : Ragini Bhakta.Atrial Fibrillation: a Patient’s Guide to Understanding Drug Therapy .JAFIB.2008 Dec;Volume 1 Issue(4): 255-256.

Atrial Fibrillation (AF) as defined by the American Heart Association is an irregular heart beat (rhythm) where the small upper chambers of the heart (atria) beat ineffectively. The atria cannot pump all of the blood out of the chambers, resulting in pooling of the blood or clot formation. Unfortunately, if a part of the clot leaves the atria, it can become lodged in an artery in the brain resulting in an ischemic stroke.

The A That Did Not Fib: Two Roads Both Traveled By

Citation : James C. Hansen,Abraham G. Kocheril.The A That Did Not Fib: Two Roads Both Traveled By .JAFIB.2008 Dec;Volume 1 Issue(4): 250-254.

Case: A 64-year-old woman presented with palpitations. Her 24-hour Holter monitor revealed runs of presumed atrial fibrillation (AF). The patient was referred for EP study and AF ablation.

EPS: At EPS, an anterograde A-H jump was noted. Spontaneous bursts of tachycardia were seen, consisting of sinus atrial beats with dual ventricular responses, each preceded by a His deflection. There was no atrial fibrillation during the study. Radiofrequency ablation of the slow AV node pathway was performed. There were no inducible tachycardias and no A-H jump following the ablation. The patient had no recurrence post-procedure.

Discussion: This case presents a rare example of simultaneous dual anterograde AV-nodal conduction. The conditions leading to this phenomenon include dual AVN pathways, markedly slowed conduction in the slow pathway, and lack of retrograde conduction up either pathway such that reentry was impossible. An irregular, narrow-complex tachycardia resulted, initially interpreted as AF. Slow-pathway ablation was curative.

The Anticoagulated Atrial Fibrillation Patient Who Requires “Curative” Therapy for Prostate Carcinoma: a Bleeding Conundrum

Citation : James A.Reiffel.The Anticoagulated Atrial Fibrillation Patient Who Requires “Curative” Therapy for Prostate Carcinoma: a Bleeding Conundrum .JAFIB.2008 Dec;Volume 1 Issue(4): 248-249.

With the aging of the population, the incidence of both prostate carcinoma (PCa) and atrial fibrillation (AF) has increased. Options for “curative therapy” PCa now include surgery, external beam radiation (EBT), and radioactive seed implantation (RSI). The latter two approaches, especially EBT, can produce radiation proctitis (RP) with rectal bleeding (RB). This poses an issue for anticoagulating the elderly AF patient who develops PCa. The attached case report of a 77 year old male who was treated with a combination of RSI and “low dose” EBT followed by recurrent severe rectal bleeding demonstrates the significance of this problem. In the AF patient with a CHADS2 score of 2 or more, and hence an indication for chronic warfarin therapy, the therapy of subsequently detected PCa requires careful consideration of the risks associated with its therapeutic options.

Is Rhythm Control with Pulmonary Vein Isolation Superior to Rate Control with AV Nodal Ablation in Patients with Heart Failure?

Citation : Dhanunjaya Lakkireddy.Is Rhythm Control with Pulmonary Vein Isolation Superior to Rate Control with AV Nodal Ablation in Patients with Heart Failure? .JAFIB.2008 Dec;Volume 1 Issue(4): 246-247.

BACKGROUND: Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure. METHODS: In this prospective, multicenter clinical trial, we randomly assigned patients with symptomatic, drug-resistant atrial fibrillation, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing. All patients completed the Minnesota Living with Heart Failure questionnaire (scores range from 0 to 105, with a higher score indicating a worse quality of life) and underwent echocardiography and a 6-minute walk test (the composite primary end point). Over a 6-month period, patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation. RESULTS: In all, 41 patients underwent pulmonary-vein isolation, and 40 underwent atrioventricular-node ablation with biventricular pacing; none were lost to follow-up at 6 months. The composite primary end point favored the group that underwent pulmonary-vein isolation, with an improved questionnaire score at 6 months (60, vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing; P<0.001), a longer 6-minute-walk distance (340 m vs. 297 m, P<0.001), and a higher ejection fraction (35% vs. 28%, P<0.001). In the group that underwent pulmonary-vein isolation, 88% of patients receiving antiarrhythmic drugs and 71% of those not receiving such drugs were free of atrial fibrillation at 6 months. In the group that underwent pulmonary-vein isolation, pulmonary-vein stenosis developed in two patients, pericardial effusion in one, and pulmonary edema in another; in the group that underwent atrioventricular-node ablation with biventricular pacing, lead dislodgment was found in one patient and pneumothorax in another. CONCLUSIONS: Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation. (ClinicalTrials.gov number, NCT00599976.) 2008 Massachusetts Medical Society

Do Statins Decrease the Arrhythmia Burden in Patients with Paroxysmal Atrial Fibrillation?

Citation : Dhanunjaya Lakkireddy.Do Statins Decrease the Arrhythmia Burden in Patients with Paroxysmal Atrial Fibrillation? .JAFIB.2008 Dec;Volume 1 Issue(4): 244-245.

Role of the Autonomic Nervous System in the Creation of Substrate for Atrial Fibrillation

Citation : Rishi Arora,Alan H. Kadish.Role of the Autonomic Nervous System in the Creation of Substrate for Atrial Fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 236-243.

Atrial fibrillation (AF) is the most common sustained arrhythmia disturbance and is associated with significant morbidity and mortality. In recent years, the pulmonary veins (PVs) and posterior left atrium (PLA) have been shown to play a significant role in the genesis of AF.


These regions have been shown to possess unique structural, electrophysiological and calcium (Ca2+) handling characteristics, all of which appear to contribute to substrate for AF.


The pathophysiology of AF is complex, and several mechanisms have been thought to contribute to the electrophysiologic and structural substrate for this arrhythmia. These mechanisms include fibrosis, stretch, inflammation and oxidative stress. In addition, neurohumoral factors have also been invoked for their possible contribution to the creation of electrophysiologic substrate for AF [3, 4]. An important neurohumoral factor that has been studied fairly extensively for its involvement in AF is the autonomic nervous system.