I97.130 Insurance Policy Changes

ICD-10 I97.130 is officially defined as "Postprocedural heart failure following cardiac surgery." code I97.130 is referenced in 5 tracked payer policy changes from Excellus BlueCross BlueShield, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code I97.130 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective May 21, 2026Medium impact
Transcatheter Heart Valve Procedures 7.01.109
Excellus policy 7.01.109 (current effective date May 21, 2026) covers transcatheter aortic valve implantation or replacement (TAVI or TAVR) for native valve aortic stenosis at any surgical risk level when all listed conditions are present, including an FDA approved device, severe aortic stenosis with a calcified valve, NYHA class II, III or IV heart failure symptoms, a left ventricular ejection fraction greater than 20%, and no unicuspid aortic valve. Transcatheter mitral valve repair or edge-to-edge repair (TMVR or TEER) may be considered medically necessary under listed criteria, and transcatheter pulmonary valve implantation may be considered medically necessary for listed congenital heart disease indications, while transcatheter tricuspid valve procedures, caval valve implantation, mitral valve implantation and annuloplasty, and cerebral embolic protection devices are investigational for all indications. The 05/21/26 revision is an annual review with policy intent unchanged.
Aetna · Identified Oct 5, 2026Medium impact
Ventricular Assist Devices (CPB 0654, reviewed 2026-09-10)
Aetna Clinical Policy Bulletin 0654 covers ventricular assist devices (VADs) and sets the criteria under which Aetna considers them medically necessary. A VAD is medically necessary as a bridge to transplant when the device has FDA approval for that indication and the member is awaiting heart transplantation. A VAD for destination therapy requires NYHA Class IV end-stage ventricular heart failure, a member who is not a candidate for heart transplant, an LVEF less than 25%, and the medical management and peak oxygen consumption criteria listed in the policy. Percutaneous VADs such as the TandemHeart and Impella are medically necessary for short-term circulatory support in cardiogenic shock and for listed high-risk PCI situations, and VADs are considered experimental, investigational, or unproven for all other indications.
Aetna · Identified Aug 18, 2026Medium impact
Ventricular Assist Devices (CPB 0654, reviewed 2026-07-17)
Aetna considers an FDA-approved ventricular assist device medically necessary as a bridge to transplant when the device has FDA approval for that indication, and as destination therapy when all of the listed criteria are met: NYHA Class IV end-stage heart failure, not a candidate for heart transplant, failure to respond to optimal medical management for at least 45 of the last 60 days (or balloon pump dependence for 7 days, or IV inotrope dependence for 14 days), LVEF less than 25%, and peak oxygen consumption less than or equal to 14 mL/kg/min. Percutaneous VADs such as the TandemHeart and the Impella are medically necessary for short-term circulatory support in cardiogenic shock and as an adjunct to high-risk PCI in the listed scenarios, and short-term LVADs, RVADs or BiVADs such as the CentriMag are medically necessary for up to 30 days in post-cardiotomy or refractory acute cardiogenic shock when the member is willing and able to be treated with heparin or an appropriate alternative anticoagulant. VADs are considered experimental, investigational or unproven for all other indications, including concomitant mitral valve surgery with LVAD implantation for mitral regurgitation, pVADs during ablation of ventricular tachycardia, implantable aortic counterpulsation ventricular assist systems, and use of mesenchymal precursor cells as adjunctive therapy in VAD recipients.
Aetna · Identified Aug 14, 2026Medium impact
Intensive Cardiac Rehabilitation Programs (CPB 0267, reviewed 2026-05-14)
Aetna considers intensive cardiac rehabilitation programs (the Benson-Henry Institute Cardiac Wellness Program, the Ornish cardiac treatment program and the Pritikin Program) medically necessary as an alternative to traditional Phase II cardiac rehabilitation for members who meet the cardiac rehabilitation criteria, limited to 72 one-hour sessions, up to 6 per day, over a period of up to 18 weeks. Virtual delivery by real-time audio and video (excluding audio-only) is considered medically necessary when the telehealth program and member criteria are met, but hospital outpatient departments are not eligible for virtual telehealth services. Intensive cardiac rehabilitation is considered experimental, investigational or unproven for diabetes, hyperlipidemia, prostate cancer, metabolic syndrome and all other indications where effectiveness has not been established.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Transcatheter Pulmonary Valve Implantation
Transcatheter pulmonary valve implantation with an FDA-approved valve is considered medically necessary for individuals with congenital heart disease and current right ventricular outflow tract (RVOT) obstruction or regurgitation, including right ventricle-to-pulmonary artery conduit or native or patched RVOT with at least moderate pulmonic regurgitation, or pulmonic stenosis with a mean RVOT gradient of at least 35 mm Hg. It is considered investigational for all other indications. The 10/19/2026 policy history entry records a description update regarding devices, with the policy statements unchanged, and a code reference update that removed ICD-9 procedure and diagnosis codes.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code I97.130?

There are 5 tracked policy changes affecting code I97.130, including updates from Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code I97.130?

Payers that have issued tracked updates for code I97.130 include: Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code I97.130 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code I97.130. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code I97.130?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Transcatheter Heart Valve Procedures 7.01.109

Ventricular Assist Devices (CPB 0654, reviewed 2026-09-10)

Ventricular Assist Devices (CPB 0654, reviewed 2026-07-17)

Intensive Cardiac Rehabilitation Programs (CPB 0267, reviewed 2026-05-14)

Transcatheter Pulmonary Valve Implantation

What insurance policy changes affect code I97.130?

Which payers have updated policy for code I97.130?

How do I get notified when code I97.130 policy changes?

Why do payers change policies for code I97.130?