33418
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
31.44
Facility
$1580.86
Non-Facility
$1580.86
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. [...]
- Aetna considers a Food and Drug Administration (FDA)-approved ventricular assist device (VAD) medically necessary for any of the following FDA-approved indications:
- As a bridge to transplant for members who are awaiting heart transplantation and the device has received FDA approval for a bridge to transplant indication (e.g., HeartMate 3 left ventricular assist system (LVAS));
- As destination therapy when all of the following criteria are met: The device has received FDA approval for a destination therapy indication; Member has New York Heart Association (NYHA) Class IV end-stage ventricular heart failure and is not a candidate for heart transplant; Member has failed to respond to optimal medical management (including beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors if tolerated) for at least 45 of the last 60 days, or has been balloon pump dependent f [...]
- Aetna considers a FDA-approved percutaneous left ventricular assist device (pVAD) (e.g., the TandemHeart and the Impella) medically necessary for the following indications: Providing short-term circulatory support in cardiogenic shock; or as an adjunct to percutaneous coronary intervention (PCI) in the following high-risk members: Members undergoing unprotected left main or last-remaining-conduit PCI with ejection fraction less than 35%; or persons with three vessel disease and ejection fraction [...]
- Aetna considers FDA-approved pediatric VADs medically necessary when both of the following criteria are met: Child has documented end-stage left ventricular failure; and an age and size-appropriate VAD will be used until a donor heart can be obtained.
7 Active Policies
AETNA-CPB-0654 — Ventricular Assist Devices
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
Related Codes
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