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Excellus BlueCross BlueShieldCommercial · Coverage · Heart & Blood Vessels (Cardiovascular) · NY · Cardiology, Cardiothoracic SurgeryMedium impact

Transcatheter Heart Valve Procedures 7.01.109

Effective date
May 21, 2026
Identified
Jun 20, 2026

Summary

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.

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What to do

Action · 5 steps
01Already effective 05/21/26: Billing team should confirm that TAVI or TAVR claims for native aortic stenosis meet the listed criteria: an FDA approved device used through an approach consistent with its labeling, severe aortic stenosis with a calcified valve, NYHA class II, III or IV symptoms, a left ventricular ejection fraction greater than 20%, and no unicuspid aortic valve.
02For aortic valve-in-valve TAVI, documentation of surgery risk must come from at least two cardiovascular specialists, including a cardiac surgeon, showing the patient is not a candidate for open surgery, is an operable candidate at high risk for open surgery, or is at increased surgical risk for open surgery.
03For TMVR or TEER, the criteria require an FDA approved device and either symptomatic primary mitral regurgitation considered at prohibitive risk for open surgery, or heart failure with moderate-to-severe or severe symptomatic secondary mitral regurgitation despite maximally tolerated guideline-directed medical therapy.
04For pulmonary valve implantation, the criteria require an FDA approved valve and congenital heart disease with current right ventricular outflow tract obstruction or regurgitation meeting one of the listed indications.
05Claims for transcatheter tricuspid valve procedures, caval valve implantation, transcatheter mitral valve implantation or valve-in-valve replacement, mitral valve annuloplasty, and cerebral embolic protection devices should be treated as investigational under this policy.

Codes mentioned

33361333623336333364333653336633367333683336933370334183341933477C1884I97.0I97.110I97.130I97.190Q21.3

Original notice

Transcatheter Heart Valve Procedures 7.01.109
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs

Excellus BlueCross BlueShield policiesNY policy changesCardiologyCardiothoracic SurgeryCode 33361Code 33362Code 33363Code 33364Code 33365Code 33366Code 33367Code 33368Code 33369Code 33370Code 33418Code 33419Code 33477Code C1884Code I97.0Code I97.110Code I97.130Code I97.190Code Q21.3

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