33367
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
11.58
Facility
$558.46
Non-Facility
$558.46
Documentation Required
- Medical records documentation may be required to assess whether the member meets clinical criteria; refer to the guidelines titled 'Medical Records Documentation Used for Reviews.' Objective echocardiographic/hemodynamic evidence as applicable (e.g., mean aortic valve gradient, peak aortic jet velocity, aortic valve area for aortic stenosis; MR grade for mitral/tricuspid regurgitation; mean RVOT gradient and degree of pulmonary regurgitation for pulmonary valve interventions). NYHA functional class documentation (e.g., II, III, IV) and documentation that symptoms are due to the valve disease targeted. Evidence of multidisciplinary heart team assessment and determination that the procedure is appropriate (for aortic, mitral, tricuspid procedures as specified). Documentation of Shared Decision Making (SDM) conversation with interventional cardiologist and experienced cardiothoracic surgeon for TAVR. Predicted Risk of Mortality (PROM/STS) score documentation when required (examples: PROM ≥ 8% for ViV aortic; PROM ≥ 8% or ≥ 6% cutoffs for mitral TEER depending on likely procedure; PROM used to define high/prohibitive surgical risk). For secondary (functional) MR: documentation of LVEF (≥ 20% and ≤ 50%), prior optimization of guideline-directed medical therapy, and evidence of cardiac resynchronization therapy when indicated. For transcatheter tricuspid repair: documentation of ≥ 30 days of stable guideline-directed medical therapy for heart failure, pulmonary artery systolic pressure (< 70 mmHg), and heart-team assessment that patient is intermediate or greater surgical risk. For TAVR center eligibility: documentation that the center meets on-site heart valve surgery and interventional cardiology program requirements, has a post-procedure ICU experienced in valve procedures, and meets CMS/STS/ACC volume and staffing criteria as detailed in the policy. Any additional testing or evaluations required for case-by-case consideration (e.g., for low-flow/low-gradient AS: dobutamine stress echocardiography and other recommended assessments per ACC/AHA guidance). For mitral valve repair requests, include: mitral regurgitation (MR) grade, NYHA classification, surgical risk using PROM score, physician composition of the care team. For tricuspid heart valve repair requests, include: tricuspid regurgitation (TR) stage, NYHA classification, pulmonary artery systolic pressure, surgical risk, physician composition of the care team. Treatments tried, failed, or contraindicated; include the dates, duration, and reason for discontinuation. Evidence that the patient is receiving stable (≥ 30 days) guideline-directed medical therapy (GDMT) for heart failure when applicable (specifically listed under tricuspid edge-to-edge repair criteria). Documentation of symptomatic status (e.g., NYHA class II or greater when applicable) and heart team determination of surgical risk (including composition of the heart team: cardiac surgery, interventional cardiology, echocardiography, heart failure specialists). General medical records documentation used for review as updated in policy (clinical notes, test results, imaging, device-specific consent and governance/audit documentation where procedures are to be used under special arrangements).
Key Coverage Criteria
- Transcatheter aortic heart valve replacement (TAVR) when performed according to FDA labeled indications, contraindications, warnings, and precautions and all of the following: diagnosis of severe calcific native aortic valve stenosis indicated by one of: mean aortic valve gradient ≥ 40 mmHg; or peak aortic jet velocity ≥ 4.0 m/s; or aortic valve area ≤ 1.0 cm². TAVR when the individual is symptomatic (NYHA class II or greater) and symptoms are due to aortic valve stenosis. [...]
- 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
4 Active Policies
UHC-POL-transcatheter-heart-valve-procedures — Transcatheter Procedures for Heart Valve Conditions
UMR-POL-UMR-transcatheter-heart-valve-procedures — Transcatheter Procedures for Heart Valve Conditions
SUREST-POL-SUREST-transcatheter-heart-valve-procedures — Transcatheter Procedures for Heart Valve Conditions
ANTHEM-SURG.00121 — SURG.00121 Transcatheter Heart Valve Procedures
Related Codes
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