CurrentAetnaPolicy 0477

Balloon Valvuloplasty

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.

Policy Summary

PayerAetna

PolicyBalloon Valvuloplasty

Policy CodePolicy 0477

Change TypeNo material change

Effective DateJul 24, 2001

Next Review DateMay 9, 2024

Key ActionObtain prior authorization when submitting CPT codes for percutaneous balloon valvuloplasty and document the specific indication and relevant clinical findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary valve indications

8mitral echo score (≤)

92987/92986/92990key covered CPT codes

Severalexperimental procedures

6,351PBMV meta-analysis n

Coverage Criteria for Percutaneous Balloon Valvuloplasty

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Medical Necessity - Mitral Valve

Covered when ANY of the following are met for severe rheumatic mitral valve stenosis:

Mitral valve covered indications: 1) Members in the second and third trimesters of pregnancy in whom balloon valvuloplasty would be expected to achieve hemodynamic and symptomatic improvement with minimal risk to the mother and fetus; OR 2) Members with favorable valve anatomy and a cumulative echocardiographic score of 8 or less; OR 3) Members with mitral valve re-stenosis after previous open surgical commissurotomy; OR 4) Members with unfavorable valve anatomy who are poor surgical candidates because of medical co-morbidities or refuse surgery.

Medical Necessity - Aortic Valve

Covered when ANY of the following are met for severe aortic valve stenosis:

Aortic valve covered indications: 1) As a 'bridge' to aortic valve replacement in members with severe heart failure who are at extremely high operative risk; OR 2) For palliative use in children with congenital critical aortic valve stenosis until the child is old enough to have a valve replacement; OR 3) Members in the second and third trimesters of pregnancy with critical aortic stenosis; OR 4) Members who are not candidates for surgical valve replacement because of medical co-morbidities, but in whom balloon valvuloplasty would be expected to palliate severe symptoms or stabilize cardiogenic shock; OR 5) Members with critical aortic stenosis who have an absolute surgical contraindication or refuse surgical treatment; OR 6) Members with severe aortic stenosis who must undergo an urgent non-cardiac operation and whose surgical risk would be reduced with hemodynamic improvement from valvuloplasty.

Medical Necessity - Pulmonary Valve

Covered when ALL of the following are met:

Pulmonary valve indication: Pulmonary valve stenosis when percutaneous balloon valvuloplasty is indicated to increase blood flow to the lungs; recognized as an established alternative to open surgical valvotomy based on limited evidence and guidance (e.g., NICE).

Evidence summaries / clinical findings

Evidence summaries and outcomes — no explicit coverage decision rules in this excerpt. Clinical findings include:

Mini-invasive radial BAV outcomes: Prospective cohort of 330 patients showed radial access in 95% with no VARC-2 major and 1.8% minor bleedings; QOL and frailty improved at 30 days; improvement in EFT associated with better 1-year survival after TAVI.

Tumscitz et al. 2021

Fetal aortic valvuloplasty (FAV) outcomes: Systematic review/meta-analysis of 266 fetuses: pooled bi-ventricular circulation ~46% among live-born, technical success 82.1%, fetal death 16%, neonatal death 8.7%; benefit for achieving BVC remains uncertain due to lack of randomized trials.

Vorisek et al. 2022

Predictors of BV outcome after FAV: Retrospective single-center data identified pre-FAV RV/LV length ratio and MR-Vmax thresholds predictive of BV outcome with high sensitivity/specificity; authors call for prospective controlled studies.RV/LV length ratio <1.094 or RV/LV 1.094-1.135 with MR-Vmax >=3.14 m/s

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

Covered CPT Codes - MitralCPTCovered

92987

Percutaneous balloon valvuloplasty; mitral valve.

Covered CPT Codes - AorticCPTCovered

92986

Percutaneous balloon valvuloplasty; aortic valve.

Covered CPT Codes - PulmonaryCPTCovered

92990

Percutaneous balloon valvuloplasty; pulmonary valve.

Other related CPT codes referencedCPT

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.

Covered ICD-10 Codes referencedICD-10Covered

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.

1–10 of 13

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Echocardiographic mitral valve score — threshold

Echocardiographic mitral valve score (threshold)Cumulative score of 8 or less indicates favorable anatomy for balloon mitral commissurotomy

Scoring scaleEach of 4 valve characteristics is graded 0–4 (0 = favorable, 4 = unfavorable)

Clinical implicationScores ≤ 8 are associated with good procedural results and are used to select candidates for balloon mitral commissurotomy

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

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.

Affected CPT codes include, but may not be limited to: 92987 (mitral) and 92986 (aortic) when selection criteria are met.
Submit supporting clinical documentation to the prior authorization review per Aetna requirements.

Documentation Required

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.

Note

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.

Note

No Additional Provider Actions Specified

None specified in this document segment.

Definitions and Assessment Scores

Echocardiographic mitral valve score — component grading (0–4 each)

Leaflet mobilityGraded 0–4 (0 = favorable mobility; 4 = severely restricted)

Valvular thickeningGraded 0–4 based on degree of leaflet thickening

Subvalvular thickeningGraded 0–4 reflecting involvement of chordae and papillary muscles

Valvular calcificationGraded 0–4 according to extent of calcific change

Bi-ventricular circulation (BVC) — definition and relevance

DefinitionBi-ventricular circulation (BVC) = postnatal circulation in which both ventricles support systemic and pulmonary blood flow

Relevance to FAV outcomesPooled BVC rate among live-born after fetal aortic valvuloplasty was ~45.8% (improves to ~51.9% with technically successful FAV); achieving BVC is an intended outcome but benefit remains uncertain due to lack of RCTs

Outcome contextAuthors caution interpreting BVC rates because randomized trials are lacking and overall fetal/neonatal risks remain substantial

EFT (Essential Frailty Toolset) — frailty assessment referenced

EFT (Essential Frailty Toolset) — purposeA frailty assessment tool used to evaluate frailty status before and after balloon aortic valvuloplasty

Prognostic associationImprovement in EFT at 30 days after BAV was associated with more favorable outcomes following TAVI; patients with EFT < 3 had lower 1-year all-cause death

Study findingIn a 330-patient mini-invasive radial BAV cohort, patients achieving EFT < 3 post-BAV had comparable 1-year mortality to those with baseline EFT < 3

OpenPayer

Balloon Valvuloplasty

Coverage Criteria for Percutaneous Balloon Valvuloplasty

Coding and Definitions

Provider Actions, Prior Authorization, and Documentation

Background

Definitions and Assessment Scores