Transcatheter Mitral Valve Repair Form

1 Transcatheter Mitral Valve Repair Medical Policy Updated Revision Effective: February 1, 2026 Policy Number: UM1003POL Approval Date: 11/11/2025 Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy) Description Mitral Valve Transcatheter Edge to Edge Repair (TEER) is used in the treatment of mitral valve regurgitation. The procedure involves clipping together a portion of the mitral valve leaflets as a treatment for reducing mitral regurgitation (MR) with the intended outcomes to improve recovery of the heart from overwork, improve function and potentially halt the progression of heart failure. Line of Business Commercial:
• Health New England (HNE) has adopted InterQual criteria for the following procedure: o Transcatheter Mitral Valve Repair (TMVr):  CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER) o Transcatheter Edge-to-Edge Mitral Valve Clip:  CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER) o Percutaneous Mitral Valve Repair:  CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER) Medicaid – BeHealthy: • HNE has adopted InterQual criteria for the following procedure: o Transcatheter Mitral Valve Repair (TMVr):

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 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

o Transcatheter Edge-to-Edge Mitral Valve Clip:

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

o Percutaneous Mitral Valve Repair:

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

• There are no MassHealth guidelines for Transcatheter Mitral Valve Edge-to-Edge Repair (TEER).

Medicare:

• Health New England (HNE) has adopted InterQual* criteria for the following procedure:

o Transcatheter Mitral Valve Repair (TMVr):

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

o Transcatheter Edge-to-Edge Mitral Valve Clip:

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

o Percutaneous Mitral Valve Repair:

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

*To obtain InterQual® SmartSheets™: Health New England Plan products: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal, call (413) 787-4004 to obtain a copy.

Policy

I. Transcatheter Mitral Valve Repair (TMVr), Transcatheter Edge-to-Edge Mitral Valve Clip and Percutaneous Mitral Valve Repair:

A. HNE has adopted the following InterQual criteria.

 CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Transcatheter Mitral Valve Repair (TMVr), Transcatheter Edge-to-Edge Mitral Valve Clip and Percutaneous Mitral Valve Repair for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

Coding Guidance

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Code
Description
PA 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis Yes 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) Yes 0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus Yes

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Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) 20.33 Transcatheter Edge- to-Edge Repair (TEER) for Mitral Valve Regurgitation.
Accessed at https://www.cms.gov/medicare-coverage-database/search.aspx

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 7/2024 Initial policy date 05/2025 Title updated to Transcatheter Mitral Valve Repair. No criteria changes. 09/2025 IQ criteria adopted for Medicare line of business.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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

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professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England 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 the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.