Does 92987 require prior authorization?

No, 92987 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 92987?

Medicare facility rate: $1205.10. Non-facility rate: $1205.10. Work RVU: 22.80.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

22.80

Facility

$1205.10

Non-Facility

$1205.10

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.

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;

AETNA-CPB-0477 — Balloon Valvuloplasty

Ask Verity about documentation requirements, denial risks, or coverage in your state.