33391
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
40.46
Facility
$2119.29
Non-Facility
$2119.29
Documentation Required
- Referral/center expertise: documentation that patient was referred to or treated at an experienced center with a program dedicated to the Ross procedure when applicable (policy notes that patients should be referred to experienced centers).
- Operative reports and procedural documentation confirming the specific procedure performed (e.g., Ross, Ross-Konno, valve-sparing re-implantation) and technique, given CPT coverage is 'if selection criteria are met.'
- The policy does not list formal, itemized documentation requirements (e.g., specific tests or forms) within the CPB text; it states covered CPT codes are covered 'if selection criteria are met' — documentation should therefore demonstrate that selection criteria and covered indications are met.
- Clinical documentation to support medical necessity should include diagnoses consistent with the covered ICD‑10 codes (listed in the policy) and clinical evidence for the specific indication (e.g., documentation of aortic stenosis, aortic incompetence/regurgitation, congenital lesion, aortic root dilatation due to Marfan syndrome, or type A acute aortic dissection as applicable).
Key Coverage Criteria
- Ross pulmonary autograft procedure for members undergoing aortic valve replacement secondary to congenital anomalies or aortic valve disease, such as: aortic incompetence (including endocarditis, rheumatism of the heart).
- Ross pulmonary autograft procedure for members undergoing aortic valve replacement for aortic stenosis.
- Ross pulmonary autograft procedure for members undergoing aortic valve replacement for congenital lesions.
- Minimally invasive approach to the aortic valve as an acceptable alternative to the conventional approach to aortic valve replacement.
- Aortic valve‑sparing re‑implantation for treatment of secondary aortic regurgitation due to aortic root dilatation (e.g., as occurs in Marfan syndrome).
- Aortic valve‑sparing re‑implantation for treatment of type A acute aortic dissection (dissection of the ascending and/or descending aorta) where valve‑sparing is indicated.
1 Active Policy
AETNA-CPB-0407 — Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation
Related Codes
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