00121
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- TAVR using a U.S. Food and Drug Administration (FDA) approved device* is consideredmedically necessarywhen the following criteria have been met:
- The individual has severe degenerative, native valve aortic stenosis demonstrated byoneof the following:The aortic valve area (AVA) is equal to or less than 1.0 cm2;orThe AVA index is equal to or less than 0.6 cm2/m2;orA mean aortic valve gradient equal to or more than 40 mm Hg;orA peak aortic-jet velocity equal to or more than 4.0 m/sec;and
- The aortic valve area (AVA) is equal to or less than 1.0 cm2;or
- The AVA index is equal to or less than 0.6 cm2/m2;or
- A mean aortic valve gradient equal to or more than 40 mm Hg;or
- A peak aortic-jet velocity equal to or more than 4.0 m/sec;and
2 Active Policies
ANTHEM-SURG.00121 — SURG.00121 Transcatheter Heart Valve Procedures
ANTHEM-CG-DME-42 — CG-DME-42 Continuous Glucose Monitoring Devices
Related Codes
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