Medicare AdvantageCoverageHigh impact
MA11.027h, Transcatheter Cardiac Valve Procedures
Independence Blue Cross·Cardiology, Cardiothoracic Surgery, Critical Care·Medical Policy
Effective date
Sep 10, 2026
We identified it
Oct 6, 2026
Summary
Independence Blue Cross updated MA11.027h to align TAVR coverage with CMS National Coverage Determination. Symptomatic severe aortic stenosis coverage changed from experimental/investigational (with CED exception) to medically necessary; asymptomatic aortic stenosis remains experimental/investigational except under CED. This expands coverage eligibility and requires billing teams to verify heart team documentation, FDA-approved valve systems, and specific clinical evaluations prior to claim submission.
Action Required
REQUIREMENTS: Already effective as of 2026-09-10: Billing team should immediately verify current practice workflows to confirm implementation of revised TAVR coverage criteria. For claims submitted on or after 2026-09-10 for symptomatic severe aortic stenosis (ICD-10 codes I06.0, I06.2, I35.0, I35.2, Q23.0), update billing system to recognize TAVR (CPT 33361) as medically necessary rather than experimental/investigational. Prior to submitting claims, verify that provider documentation includes: (1) heart team evaluation with both cardiac surgeon and interventional cardiologist input, (2) in-person (not virtual) evaluation by heart team TAVR operator, (3) FDA PMA-approved valve system confirmation, and (4) documented suitability assessment for TAVR vs. SAVR vs. surveillance vs. palliative care. For asymptomatic severe aortic stenosis, continue to process claims only under CED program with Q0 modifier. Contact Independence Blue Cross to confirm whether the practice has received prior authorization system updates and obtain current CED approval list from CMS website (https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/). Claims lacking required heart team documentation will likely be denied or require resubmission.