Transcatheter Pulmonary Valve Implantation

This policy covers transcatheter pulmonary valve implantation (TPVI), including use of the Melody transcatheter pulmonary valve system, for patients with congenital heart disease who have right ventricular outflow tract (RVOT) obstruction or regurgitation—examples include dysfunctional right ventricle‑to‑pulmonary artery conduits or surgical bioprosthetic pulmonary valves (valve‑in‑valve) with at least moderate pulmonic regurgitation or RVOT stenosis (mean gradient ≥35 mm Hg). Coverage is limited to procedures using an FDA‑approved valve and generally requires a circumferential RVOT conduit that was originally ≥16 mm in diameter; indications not listed as medically necessary are considered experimental/investigational and actual coverage is subject to the member’s benefit plan and applicable state/regulatory restrictions.

"Individuals with congenital heart disease and current right ventricular outflow tract (RVOT) obstruction or regurgitation."