Carelon Requires Peer-to-Peer Discussion for Approval of CPT Code 93657

HRS recently met with Carelon Medical Benefits Management to discuss a change to clinical guidelines for transcatheter ablation for management of atrial fibrillation (AF). A new claims grouper for CPT code 93657 was implemented on March 1, 2026, to designate additional linear or focal ablation of the left or right atrium for AF, performed at the time of PVI (CPT code 93656) as not medically necessary. Approval of 93657 will require a peer-to-peer discussion to override the guideline.

The ordering physician can request a peer-to-peer discussion with Carelon Medical Benefits Management before service or after service is performed and a coverage determination is made.

When providers request PVI prior to service, they can either request 93656 alone or in combination with 93657.  If criteria for 93656 are met, an approval will be issued.   Based on guideline criteria, approval of 93657 would require a peer-to-peer discussion resulting in an override of the guideline.  Therefore, a peer-to-peer discussion will be offered for 93657.

If a provider requests (and gets approval for) 93656 alone, and then at the time of service performs additional linear ablations, he/she can come back post service (within 2 days) to create a separate request for authorization of 93657. Post-approval of 93657 would still require a peer-to-peer discussion to override the guideline.  In the future, the 2 day window will be prolonged to a 10 day window.