Transcatheter aortic valve implantation (TAVI) 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.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Coverage is subject to the specific terms of the member’s benefit plan.
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:
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 bed bound individuals; and
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:
TAVR is considered not medically necessary when performed for indications other than those listed in the above criteria.
Covered Diagnosis Codes for procedure codes 33361, 33362, 33366, 93591