HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
S-232-009
Topic:
Transcatheter Aortic Valve Replacement (TAVR)
Section:
Surgery
Effective Date:
April 15, 2019
Issued Date:
April 15, 2019
Last Revision Date:
March 2019
Annual Review:
March 2019
 
 

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.

Policy Position

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 0.8 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
    • A peak 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; 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 an operable candidate but is at immediate risk or high risk for open surgery.

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

33361

33362

33363

33364

33365

33366

33367

33368

33369

93591

 

 

 

 


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

I06.0

I06.2

I35.0

I35.1

I35.2

I35.8

I35.9


Place of Service: Inpatient


The policy position applies to all commercial lines of business



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.