Transcatheter Procedures for Heart Valve Conditions – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare covers transcatheter valve procedures only when performed per FDA labeling and specified clinical criteria — for example, TAVR for symptomatic severe calcific aortic stenosis meeting echocardiographic thresholds (mean gradient ≥40 mmHg or peak velocity ≥4.0 m/s or valve area ≤1.0 cm²), TEER for mitral MR meeting MR grade, NYHA and PROM/surgical‑risk thresholds, transcatheter pulmonary valve replacement per RVOT criteria, and edge‑to‑edge tricuspid repair for symptomatic severe TR after ≥30 days stable GDMT with NYHA II+ and heart‑team determination of intermediate or greater surgical risk. Procedures/devices deemed unproven and generally not covered include many transcatheter mitral/tricuspid reconstructions or replacements, ViV outside the aortic position, cerebral protection devices, CAVI, etc., and all covered interventions require multidisciplinary heart‑team evaluation, detailed documentation (echo/hemodynamics, NYHA, PROM/STS scores, SDM for TAVR), and performance at centers meeting CMS/STS/ACC program and volume/staffing requirements.