CommercialCoverageMedium impact
Transcatheter Tricuspid Valve Repair or Replacement (2.02.34)
Blue Shield of California·CA · Cardiology, Cardiothoracic Surgery·Medical Policy
Effective date
Jul 1, 2025
We identified it
Jul 1, 2025
Summary
Blue Shield of California established new medical policy 2.02.34 effective July 1, 2025, covering transcatheter tricuspid valve repair (T-TEER) and replacement (TTVR) procedures for patients with severe tricuspid regurgitation who are intermediate/high surgical risk candidates. The policy defines specific FDA-approved devices (TriClip for repair, EVOQUE for replacement) as medically necessary under strict criteria including heart team evaluation and maximally tolerated medical therapy.
Action Required
By July 1, 2025: Billing team must update prior authorization requirements for transcatheter tricuspid valve procedures to ensure patients meet medical necessity criteria including severe TR despite optimal medical therapy, intermediate/high surgical risk assessment by heart team, and use of FDA-approved devices only. Verify contraindications are documented and that continuing evidence development requirements are met for TriClip and EVOQUE procedures.