Prior authorization request form Form

Transcatheter Aortic Valve Replacement

Last Review Date: October 10, 2025 
Number: MG.MM.SU.54fC4

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definition Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation [TAVI) is a minimally invasive procedure for the treatment of aortic stenosis. A bioprosthetic valve is implanted percutaneously in the orifice of the native aortic valve. There are two access routes for TAVI— transfemoral and transapical (involving thoracotomy).

Guideline Members are eligible for TAVR coverage when the method of insertion and clinical indication are commensurate with the FDA’s approval of the device and when the following criteria are met:

1. Severe native valve aortic stenosis or failure defined by ≥ 1 of the following:
   a. Mean aortic valve gradient ≥ 40mmHg
   b. Peak jet velocity ≥ 4.0 m/s
   c. Aortic valve area (AVA) < 0.8 cm2
   d. AVA Index < 0.6 cm2/m2

2. Presence of symptomatic aortic stenosis
   TAVR, as a repair to a previously implanted bio-prosthetic valve (“valve-in-valve”) that has degenerated, is considered medically necessary for members at high or greater risk for open surgery (i.e., Society of Thoracic Surgeons operative risk score of ≥ 8 % or ≥ 15 % risk of mortality for surgical replacement).

   Limitations/Exclusions TAVR is not considered medically necessary for members with existing co-morbidities that would preclude the expected benefit from correction of the aortic stenosis.

Revision History Oct. 8, 2021 Changed prerequisite language to “Presence of symptomatic aortic stenosis” instead of “Presence of New York Heart Association (NYHA) symptoms ≥ class II symptomatic aortic stenosis” Nov. 11. 2019 Removed surgical risk prerequisite May 9, 2019 Added positive coverage for valve-in-valve repair to a previously implanted valve Nov. 21, 2016 Removed provider and facility credentialing prerequisite Applicable Procedure Codes 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach 33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) 33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy)
33367 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) 33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) 33369 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) 33370 Transcatheter placement and subsequent removal of cerebral embolic protection device(s), including arterial access, catheterization, imaging, and radiological supervision and interpretation, percutaneous (List separately in addition to code for primary procedure)
Applicable ICD-10 Diagnosis Codes I06.0 Rheumatic aortic stenosis I06.2 Rheumatic aortic stenosis with insufficiency I06.8 Other rheumatic aortic valve diseases I06.9 Rheumatic aortic valve disease, unspecified I08.0 Rheumatic disorders of both mitral and aortic valves I08.8 Other rheumatic multiple valve diseases I08.9 Rheumatic multiple valve disease, unspecified I35.0 Nonrheumatic aortic (valve) stenosis I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency Q23.0 Congenital stenosis of aortic valve

References Low-Risk Patients. 2 May 2019. The New England Journal of Medicine. Volume 380, Number 18. 1695-1700.
Nishimura R, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 Guideline for the management of patients with valvular heart disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2017; 70(2):252-289. Nishimura RA, O’Gara PT, Bavaria JE, et al. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patient with Valvular Heart Disease. J Am Coll Cardiol, May 2019. Vol. 73, Issue 20. DOI: 10.1016/j.jacc.2018.10.007.
Saurabh Sanon, MD et al. Transcatheter Tricuspid Valve-in-Valve and Valve-in-Ring Implantation for Degenerated Surgical Prosthesis. JACC: Cardiovascular Interventions. August 2019. Volume 12, Issue 15. DOI: 10.1016/j.jcin.2019.05.029.
Denisa Muraru, MD PhD et al. Transcatheter Tricuspid Valve Replacement. Journal of the American College of Cardiology. January 2019. Volume 73, Issue 2. DOI: 10.1016/j.jacc.2018.09.087
Feldman T, Saibal K, Elmariah S, et al. Randomized comparison of percutaneous repair of surgery for mitral regurgitation. 5-year results of EVERST II. JACC. 2015; 66(25):2844-285. Specialty matched clinical peer review.