Description

Transcatheter aortic valve replacement (TAVR) is a potential alternative treatment for individuals with severe aortic stenosis. Many individuals with aortic stenosis are very elderly and/or have multiple medical comorbidities, indicating high-risk and often prohibitive for surgery. This procedure is being evaluated as an alternative to open surgery for high-risk individuals with aortic stenosis and as an alternative to non-surgical therapy for individuals with a prohibitive risk for surgery.

Criteria

TAVR performed via the transfemoral or transapical approach,for severe aortic stenosis, using a Food and Drug Administration (FDA)-approved Transcatheter Heart Valve System, may be considered medically necessary when ALL of the following criteria are met:

• The individual has aortic stenosis with a calcified aortic annulus, as defined by ONE or MORE of the following criteria:
  • An aortic valve area of less than 1.0 cm²; or
  • An aortic valve area index of less than or equal to 0.6 cm²/m²; or
  • A mean aortic valve gradient greater than 40 mmHg; or
  • Apeak aortic-jet velocity greater than 4.0 m/sec; and
• The individual has New York Heart Association (NYHA) Classification II, III or IV symptoms:
  I.No symptoms and no limitation in ordinary physical activity, (e.g., shortness of breath when walking, climbing stairs etc.).
  II. Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
  III. Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g., walking short distances (20-100m). Comfortable only at rest.
  IV. Severe limitations. Experiences symptoms even while at rest. Mostly bedbound individuals; and
• Left ventricular ejection fraction greater than 20%; and
• The individual is not an operable candidate for open surgery, as determined by at least two (2)cardiovascular specialists (cardiologist and/or cardiac surgeon); or individual is an operable candidate but is at intermediate risk or high risk for open surgery;or individual is at low to high risk for death and complications with open-heart surgery, and
• The procedure is being performed by a professional provider and at a facility that meets the recommendations for performing TAVR, as set forth in the Credentialing Recommendations for Heart Valve Replacement Procedure, established in collaboration with the following cardiovascular specialty societies: the American College of Cardiology Foundation (ACCF), the Society for Cardiovascular Angiography and Interventions (SCAI), the American Association for Thoracic Surgery (AATS), and the Society of Thoracic Surgeons (STS).

TAVR with a transcatheter heart valve system approved for use for repair of a degenerated bioprosthetic valve may be considered medically necessary when ALL of the following conditions are present:

• Failed (stenosed, insufficient, or combined) of a surgical bioprosthetic aortic valve; and
• NYHA heart failure class II, III or IV symptoms; and
• Left ventricular ejection fraction greater than 20%; and
• The individual is not an operable candidate for open surgery, as determined by at least two (2) cardiovascular specialists (cardiologist and/or cardiac surgeon) or individual is at low to high risk for death and complications with open-heart surgery.

TAVR is considered not medically necessary when performed for indications other than those listed in the above criteria.

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for procedure codes 33361, 33362, 33363, 33364, 33365, 33366, 93591

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 (Revised policy criteria an aortic valve area of less than 0.8 revised to1.0 cm2; Added or individual is at low to high risk for death and complications with open-heart surgery)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.