CommercialCoverageHigh impact
Transcatheter Aortic Valve Implantation (CPB 0826, reviewed 2025-12-03)
Aetna·Cardiology, Cardiothoracic Surgery, Critical Care +1 more·Surgery
Effective date
Dec 3, 2025
We identified it
Aug 18, 2026
Summary
Aetna's TAVI (Transcatheter Aortic Valve Implantation) policy CPB 0826 establishes coverage criteria for multiple valve replacement approaches with specific FDA-approved devices and clinical risk thresholds. The policy clearly delineates covered procedures (TAVI for high-risk/inoperable patients, valve-in-valve replacements, paravalvular leak repairs) from non-covered experimental procedures (BASILICA, embolic protection devices, pre-implant balloon valvuloplasty). Billing teams must verify patient risk scores, device types, and clinical indications before claim submission to ensure medical necessity.
Action Required
Immediately: Billing team must implement pre-claim verification process for all TAVI procedures (CPT 33361-33369, 93590-93592). For EACH claim, verify and document: (1) Patient meets ONE of the three coverage pathways (inoperable, STS score ≥8% or ≥15% mortality risk, or low-risk), (2) Device used is FDA-approved (Edwards Sapien 3/XT, Medtronic CoreValve only), (3) Ejection fraction >20% documented, (4) No severe aortic insufficiency present, (5) For valve-in-valve: prior bioprosthetic valve confirmed degenerated. DO NOT bill CPT 33370 (embolic protection device), CPT 92986 with pre-implant valvuloplasty, or combinations with LAA occlusion—these are non-covered. Do not bill for TAVI in sepsis/endocarditis, bicuspid stenosis, aortic regurgitation, or porcelain aorta. For paravalvular leak repairs (CPT 93590-93592): verify intractable hemolysis OR NYHA Class III/IV symptoms AND high/prohibitive surgical risk AND suitable anatomy AND comprehensive valve center designation. Update EMR templates and billing software to require provider attestation of STS risk score or 15% mortality risk assessment before claim submission. Add mandatory fields: (a) Risk stratification method used, (b) FDA device name/model, (c) Ejection fraction percentage, (d) Aortic insufficiency severity grade. Claims submitted without complete risk documentation will be denied. Flag any claims mentioning BASILICA procedure, embolic protection, pre-implant balloon valvuloplasty, nitric oxide biomarkers, urinary biomarkers, or CO2 gap testing for denial—these are experimental/non-covered per policy. Cardiology and cardiac surgery departments must be notified immediately of these requirements.