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Balloon Valvuloplasty
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Medical policy governing indications, coverage stance, and coding for percutaneous balloon valvuloplasty (mitral, aortic, pulmonary) and selected investigational uses; applies to Aetna members and providers submitting claims to Aetna.
No material clinical or coverage changes in this revision.
Coverage Criteria for Percutaneous Balloon Valvuloplasty
Medical Necessity - Mitral Valve
Covered when ANY of the following are met for severe rheumatic mitral valve stenosis:
Medical Necessity - Aortic Valve
Covered when ANY of the following are met for severe aortic valve stenosis:
Medical Necessity - Pulmonary Valve
Covered when ALL of the following are met:
Evidence summaries / clinical findings
Evidence summaries and outcomes — no explicit coverage decision rules in this excerpt. Clinical findings include:
Tumscitz et al. 2021
Vorisek et al. 2022
Tulzer et al. 2022
Liu et al. 2022
Percutaneous balloon aortic valvuloplasty (BAV) and other balloon valvuloplasty approaches may be used in specialized circumstances but several specific uses are designated as experimental/investigational and excluded from coverage. The policy lists BAV for selection of proper transcatheter heart valve (THV) size and percutaneous balloon valvuloplasty for bioprosthetic tricuspid valve stenosis among procedures considered experimental because effectiveness has not been established. Case series and limited reports of percutaneous tricuspid balloon valvuloplasty (PTTBV) for bioprosthetic tricuspid stenosis exist, with some successful outcomes, but authors note absence of randomized controlled trials and caution that surgical correction remains the preferred therapy for most patients.
Fetal aortic valvuloplasty (FAV) is described in the literature as an intervention with promising technical success in experienced centers but with uncertain clinical benefit. Published single‑center and systematic reports note a relatively high technical success rate but also significant fetal and neonatal mortality, and authors explicitly state that in the absence of randomized controlled trials, FAV remains experimental and its benefit for achieving a biventricular circulation is not proven.
Use of balloon valvuloplasty for indications not enumerated as medically necessary in this policy is considered experimental/investigational and not medically necessary. This specifically includes BAV performed solely to size a transcatheter heart valve (THV) and percutaneous balloon valvuloplasty for bioprosthetic tricuspid valve stenosis; while case reports and small series describe occasional success with PTTBV for bioprosthetic tricuspid stenosis, the evidence is limited and surgical replacement remains the standard of care.
Authors reviewing fetal aortic valvuloplasty outcomes emphasize that although procedural technical success can be high in experienced centers, meaningful improvement in postnatal biventricular circulation is uncertain and the procedure should be regarded as experimental until randomized controlled data demonstrate net benefit. Published analyses call for cautious patient selection and further prospective controlled study before wider adoption.
Coding and Definitions
| 92987 | Percutaneous balloon valvuloplasty; mitral valve. |
| 92986 | Percutaneous balloon valvuloplasty; aortic valve. |
| 92990 | Percutaneous balloon valvuloplasty; pulmonary valve. |
| 33476 | Right ventricular resection for infundibular stenosis, with or without commissurotomy. |
| 33478 | Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection. |
| 33405-33413 | Replacement of aortic valve. |
| 33460 | Valvectomy, tricuspid valve, with cardiopulmonary bypass. |
| 33463 | Valvuloplasty, tricuspid valve; without ring insertion. |
| 33464 | Valvuloplasty, tricuspid valve; with ring insertion. |
| 93303-93350 | Echocardiography. |
| I05.0 | Rheumatic mitral stenosis. |
| I05.2 | Rheumatic mitral stenosis with insufficiency. |
| I08.0 | Rheumatic disorders of both mitral and aortic valves. |
| I08.8 | Other rheumatic multiple valve diseases. |
| O99.412-O99.413 | Diseases of the circulatory system complicating pregnancy, 2nd or 3rd trimester. |
| I06.0 | Rheumatic aortic stenosis. |
| I06.2 | Rheumatic aortic stenosis with insufficiency. |
| I35.0-I35.9 | Nonrheumatic aortic valve disorders. |
| Q23.0 | Congenital stenosis of aortic valve. |
| Q25.21-Q25.4 | Congenital malformations of great arteries. |
Provider Actions, Prior Authorization, and Documentation
Prior Authorization Required
Prior authorization is required for covered valvuloplasty CPT codes. Coverage is contingent on meeting the policy's medical criteria and on completion of the Aetna prior authorization review process applicable to the member's plan.
Documentation Requirements
Documentation should clearly support the specific indication and clinical rationale for the procedure, including relevant diagnostic findings, echocardiographic scores or anatomic assessments, pregnancy status when applicable, prior surgical history, and reasons the member is a poor surgical candidate when relevant.
- Include echocardiographic valve score when mitral stenosis is the indication (score ≤ 8 for favorable anatomy).
- For pregnancy-related indications, document gestational trimester and expected benefit/risk.
- For bridge or palliative uses, document severity of symptoms and operative risk.
Provide Policy References and Review History
Providers should supply relevant clinical documentation consistent with Aetna requirements. The policy includes references and a review history; absence of required documentation or plan-specific prior authorization may affect coverage decisions.
- See the policy Review History and Clinical Policy Bulletin Notes for additional procedural and administrative guidance.
- Ensure submissions reference the policy number (0477) and effective date as needed.
No Additional Provider Actions Specified
None specified in this document segment.
Background
Balloon valvuloplasty (also termed valvotomy or commissurotomy) is a percutaneous transcatheter technique in which one or more balloons are positioned across a stenotic cardiac valve and inflated to split fused commissures or dilate the valve orifice to reduce transvalvular obstruction. The procedure is established therapy in selected settings — for example, balloon mitral commissurotomy is preferred for adult rheumatic mitral stenosis with favorable anatomy (echocardiographic score ≤ 8), balloon valvuloplasty is standard for congenital critical aortic stenosis in children, and pulmonary valve stenosis can often be managed percutaneously as an alternative to open surgical valvotomy.
Definitions and Assessment Scores
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