Balloon Valvuloplasty (CPB 0477, reviewed 2026-07-17)

By 2026-07-17: Billing team must update claim submission rules in billing software to enforce coverage criteria for balloon valvuloplasty procedures. (1) For CPT 92986 (aortic valve): Require documentation that the procedure meets one of six covered indications (bridge to TAVI/SAVR, pediatric palliative use, pregnancy, non-surgical candidates with severe symptoms, critical stenosis with absolute contraindication/refusal, or urgent non-cardiac operation). Reject claims citing only cardiogenic shock (R57.0) as indication. (2) For CPT 92987 (mitral valve): Require echocardiographic score of 8 or less OR pregnancy documentation OR previous commissurotomy evidence OR surgical candidacy documentation. (3) For CPT 92990 (pulmonary valve): Accept without additional criteria. (4) DENY all claims for: balloon aortic valvuloplasty for THV sizing selection, combined pulmonary valvuloplasty with conal artery occlusion, bioprosthetic tricuspid valve stenosis procedures, and simultaneous TAVR/pulmonary valvuloplasty. Modify encounter forms and prior authorization templates to require providers to document specific covered indications. Train coding and prior authorization staff on experimental procedures list. Failure to apply these criteria will result in claim denials and potential overpayments.