Does Medicare Cover Heart Ablation?

Heart ablation is a medical procedure for irregular heart rhythms. It targets and modifies heart tissue responsible for abnormal electrical signals, restoring a normal heart rate. Understanding how Medicare covers the procedure is important for financial planning and accessing care. This article explains Medicare coverage for heart ablation and outlines financial responsibilities.

Understanding Heart Ablation and Medicare Coverage

Heart ablation is a procedure that corrects irregular heartbeats, such as atrial fibrillation (AFib) and supraventricular tachycardia (SVT). During the procedure, doctors use catheters, guided through blood vessels to the heart, to deliver energy that creates small scars to block irregular electrical pathways. This process helps the heart beat more regularly and can alleviate symptoms like palpitations, dizziness, and fatigue. Surgical ablation, a more complex approach, may involve open-heart surgery.

Medicare covers heart ablation when it is determined to be medically necessary. Coverage depends on where the procedure is performed. Medicare Part A covers inpatient hospital stays, including the facility costs and related services if the ablation requires an overnight stay in a hospital. Medicare Part B covers outpatient procedures, doctors’ services, and diagnostic tests performed before or after the ablation.

Original Medicare, comprising Part A and Part B, provides coverage for heart ablation, including both catheter and surgical ablation. Medicare Advantage plans, also known as Part C, also cover this procedure. While Medicare Advantage plans offer the same coverage as Original Medicare, their out-of-pocket costs and network requirements can differ significantly.

Specific Coverage Requirements and Services

For heart ablation to be covered by Medicare, it must be deemed medically necessary by a doctor. This means there is a confirmed diagnosis of a treatable arrhythmia, such as atrial fibrillation. Medicare coverage is considered after less invasive treatments, like medications, have been attempted but have not been effective in managing the condition.

Medicare also covers related services for heart ablation. This includes pre-procedure diagnostic tests, such as electrophysiology studies, which map the heart’s electrical activity to pinpoint the source of the irregular rhythm. Anesthesia administered during the procedure, facility fees for the hospital or outpatient center, and the professional fees of the surgeons and cardiologists involved are also covered.

The Centers for Medicare & Medicaid Services (CMS) continually updates its coverage policies. Pulsed field ablation, a newer technique using electrical pulses, was added as a covered option for cardiac ablation patients in 2024.

Your Financial Responsibility

Even with Medicare coverage, beneficiaries have financial responsibilities for heart ablation. These out-of-pocket costs include deductibles, coinsurance, and copayments. For 2025, the Medicare Part A inpatient hospital deductible is $1,676 per benefit period, which covers the first 60 days of a hospital stay.

If an inpatient stay extends beyond 60 days, a daily coinsurance applies: $419 per day for days 61 through 90, and $838 per day for lifetime reserve days from day 91 onward. For services covered under Medicare Part B, such as outpatient ablation, the annual deductible for 2025 is $257. After this deductible is met, Medicare Part B covers 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance.

Medicare Advantage (Part C) plans handle costs differently. These plans may have varying copayments, deductibles, and out-of-pocket maximums, which can influence the total cost of a heart ablation. The maximum out-of-pocket limit for in-network services under Medicare Advantage plans for 2025 is $9,350, though many plans have lower caps.

Many beneficiaries choose to purchase Medicare Supplement Insurance, also known as Medigap, to help cover some of these out-of-pocket expenses. Medigap policies can help pay for deductibles, coinsurance, and copayments that Original Medicare does not cover. These plans are standardized and help reduce financial unpredictability.

Navigating the Coverage Process

Securing Medicare coverage for heart ablation involves administrative steps, beginning with your treating physician. Your doctor plays a central role by determining the medical necessity of the procedure and submitting the required documentation to Medicare. This documentation supports the claim that the ablation is an appropriate and necessary treatment for your condition.

Prior authorization may be required for heart ablation, particularly for certain procedures or under specific Medicare Advantage plans. This process involves obtaining approval from Medicare or your Medicare Advantage plan before the procedure is performed. Your physician’s office handles this, providing the necessary clinical information to justify the treatment.

After receiving medical services, beneficiaries with Medicare Advantage or Part D plans receive an Explanation of Benefits (EOB) statement. This document summarizes the services received, the amount billed, the portion covered by the plan, and any remaining amount owed by the beneficiary. It is important to remember that an EOB is not a bill, but rather a summary of processed claims.

If a claim for heart ablation coverage is initially denied, beneficiaries have the right to appeal the decision. The Medicare appeals process involves multiple levels, allowing you to challenge a denial if you believe it was made in error. This process begins with a request for redetermination and may escalate through several stages, including hearings and judicial review.