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.
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:
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, 33363, 33364, 33365, 33366, 93591
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)
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.