92986
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
22.04
Facility
$1168.03
Non-Facility
$1168.03
Documentation Required
- Appropriate ICD-10 diagnosis codes corresponding to the covered indications (as listed in policy) and CPT procedure code (92986, 92987, 92990) on claims; supporting clinical records as above.
- Relevant pre-procedure clinical notes, informed consent, and procedure reports (including number and size of balloon inflations, immediate hemodynamic results, and complications) to support medical necessity and claim.
- Echocardiographic assessment documenting valve anatomy and scoring for mitral stenosis (echocardiographic criteria: leaflet mobility; valvular thickening; subvalvular thickening; valvular calcification) with cumulative score and documentation that score is 8 or less when claiming coverage for favorable-anatomy mitral valvuloplasty.
- Echocardiogram and/or other imaging documenting severity of aortic, mitral or pulmonary valve stenosis (e.g., gradients, valve area) when used to justify medical necessity.
Key Coverage Criteria
- Severe rheumatic mitral valve stenosis in members who meet any of the following: Members in the second and third trimesters of pregnancy in whom balloon valvuloplasty would be expected to achieve hemodynamic and symptomatic improvement with minimal risk to the mother and fetus;
- Severe rheumatic mitral valve stenosis in members with favorable valve anatomy and a cumulative score of 8 or less on echocardiographic criteria;
- Severe rheumatic mitral valve stenosis in members with mitral valve re-stenosis after previous open surgical commissurotomy;
- Severe rheumatic mitral valve stenosis in members with unfavorable valve anatomy who are poor surgical candidates because of medical co-morbidities or refuse surgery;
- Severe aortic valve stenosis in members who meet any of the following: As a 'bridge' to aortic valve replacement in members with severe heart failure who are at extremely high operative risk;
- Severe aortic valve stenosis as palliative use in children with congenital critical aortic valve stenosis, until the child is old enough to have a valve replacement;
1 Active Policy
AETNA-CPB-0477 — Balloon Valvuloplasty
Related Codes
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