Transcatheter Aortic Valve Replacement (TAVR) Form

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Transcatheter Aortic Valve Replacement (TAVR) Medical Policy Updated Revision Effective: 10/1/2025 Policy Number: UM1006POL

Approval Date:

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Aortic stenosis (AS) is caused by narrowing of the aortic valve opening which results in impeding blood flow from the heart to the rest of the body. Aortic stenosis is a progressive and variable disease. Although patients may initially be asymptomatic, careful monitoring is recommended because the development of symptoms can be subtle and often goes unrecognized by the individual. Initial complaints may include dyspnea on exertion and progressive exercise intolerance; angina, syncope, and heart failure indicate advanced disease. Intervention is recommended for patients with severe AS.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure in which a bioprosthetic valve is inserted via a catheter and implanted into the diseased native aortic valve or failed bioprosthetic valve without the need for open heart surgery. For most patients, the 2020 American Heart Association and American College of Cardiology guidelines recommend TAVR as an alternative to surgical aortic valve replacement (SAVR). The Placement of Aortic Transcatheter Valve (PARTNER) trial demonstrated that TAVR was noninferior to SAVR for 1, 2, and 5-year all-cause mortality for high-risk patients with severe AS. The CoreValve U.S. Pivotal High-Risk trial validated these findings at 1, 2, and 5 years. The PARTNER 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) trials randomized intermediate-risk patients to either SAVR or TAVR, finding TAVR to be noninferior to SAVR for the outcomes of death or disabling stroke at 2 years.

Transfemoral access is the preferred approach for transcatheter aortic valve replacement (TAVR) and has been validated in clinical trials. Alternative approaches, such as transapical, transsubclavian, and transaortic approaches can be used for patients with peripheral vascular and aortic disease prohibiting transfemoral access; however, these can be more invasive and there is a lack of clinical trials comparing the benefits and risks of these various approaches. American College of Cardiology and American Heart Association guidelines recommend surgical aortic valve replacement if transfemoral TAVR is not feasible.

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 Line of Business

Commercial:

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

o Transfemoral Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach

o Transaortic Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

o Transapical Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

o Transcatheter Aortic Valve Insertion (TAVI):

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

o Transsubclavian Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

Medicaid – BeHealthy:

• HNE has adopted InterQual* criteria for the following procedures:

o Transfemoral Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach

o Transaortic Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

o Transapical Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

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o Transcatheter Aortic Valve Insertion (TAVI):

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

o Transsubclavian Transcatheter Aortic Valve Replacement:

 CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach  CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

Medicare:

• HNE has adopted InterQual* criteria for the following procedures:

o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), NCD, Transcatheter Aortic Valve Replacement - NCD o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Transcatheter Aortic Valve Replacement Clinical Trial – NCD o This criterion is based on CMS NCD for Transcatheter Aortic Valve Replacement (TAVR) (20.32)

• The following National Coverage Determination (NCD) or Local Coverage Determination (LCD) can be found at MCD Search (cms.gov):

o (NCD) 20.32 Transcatheter Aortic Valve Replacement (TAVR).

*To obtain InterQual® SmartSheets™: 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 Aortic Valve Replacement (TAVR), Femoral Approach

A. HNE has adopted the following InterQual criteria.

o Transfemoral Transcatheter Aortic Valve Replacement: CP: Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach o Transaortic Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach o Transapical Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach o Transcatheter Aortic Valve Insertion (TAVI): CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach o Transsubclavian Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), NCD, Transcatheter Aortic Valve Replacement – NCD o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Transcatheter Aortic Valve Replacement Clinical Trial – NCD

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

C. Transcatheter Aortic Valve Replacement (TAVR), Femoral Approach for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

II. Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach

A. HNE has adopted the following InterQual criteria.

o Transaortic Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach o Transapical Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach o Transcatheter Aortic Valve Insertion (TAVI): CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach o Transsubclavian Transcatheter Aortic Valve Replacement: CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), NCD, Transcatheter Aortic Valve Replacement – NCD o CP:Procedures, Transcatheter Aortic Valve Replacement (TAVR), Transcatheter Aortic Valve Replacement Clinical Trial – NCD

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

C. Transcatheter Aortic Valve Replacement (TAVR), Nonfemoral Approach for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

Coding Guidance

Code
Description
PA 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach Yes 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach Yes 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach Yes 33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach Yes 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) Yes 33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) Yes

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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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

2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Otto et al., Circulation 2021, 143: e35-e71; https://pubmed.ncbi.nlm.nih.gov/33332150/

2017 ESC/EACTS Guidelines for the management of valvular heart disease. Baumgartner et al., Eur Heart J 2017, 38: 2739-91;
https://pubmed.ncbi.nlm.nih.gov/28886619/

ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. Bonow et al., J Am Coll Cardiol 2017, 70: 2566-98;
https://www.jacc.org/doi/10.1016/j.jacc.2017.09.018

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Nishimura et al., Circulation 2017, 135: e1159-e1195; https://www.ahajournals.org/doi/10.1161/CIR.0000000000000503 2014 AHA/ACC 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.
Nishimura et al., J Thorac Cardiovasc Surg 2014, 148: e1-e132.
https://pubmed.ncbi.nlm.nih.gov/24939033/

5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomized controlled trial.
Mack et al., Lancet 2015, 385: 2477-84;
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60308-7/abstract

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis. Makkar et al., N Engl J Med 2012, 366: 1696-704; Leon et al., N Engl J Med 2010, 363: 1597-607 https://www.nejm.org/doi/pdf/10.1056/NEJMoa1202277?listPDF=true

5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients. al., J Am Coll Cardiol 2018, 72: 2687-96;
https://www.jacc.org/doi/10.1016/j.jacc.2018.08.2146

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2-Year Outcomes in Patients Undergoing Surgical or Self-Expanding Transcatheter Aortic Valve Replacement. Reardon et al., J Am Coll Cardiol 2015, 66: 113-21;
https://pubmed.ncbi.nlm.nih.gov/26055947/

Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis.
Adams et al., N Engl J Med 2014, 370: 1790-8.
https://www.nejm.org/doi/full/10.1056/NEJMoa1400590

Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients.
Reardon et al., N Engl J Med 2017, 376: 1321-31;
https://www.nejm.org/doi/full/10.1056/NEJMoa1700456

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients.
Leon et al., N Engl J Med 2016, 374: 1609-20.
https://www.nejm.org/doi/full/10.1056/NEJMoa1514616

2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
Bavaria et al., J Am Coll Cardiol 2019, 73: 340-74;
https://www.jacc.org/doi/10.1016/j.jacc.2018.07.002

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.
Otto et al., J Am Coll Cardiol 2017, 69: 1313-46.
https://www.jacc.org/doi/10.1016/j.jacc.2016.12.006

Transcatheter aortic valve replacement with a focus on transcarotid: a review of the current literature.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787377/

Transcarotid Access Versus Transfemoral Access for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190826/

Alternate Access for TAVI: Stay Clear of the Chest.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234489/

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

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Date Update 06/2024 New Policy. 04/2025 Added InterQual for Medicare NCD.

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 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.