Transcatheter Valve Replacement or Repair (TAVR, TPVI, TMVR, TMVI)
Defines medical necessity and prior authorization requirements for transcatheter valve replacement and repair procedures (TAVR, TPVI, TMVR, TMVI) for Baylor Scott & White Health Plan members; applies across lines of business with references to Medicare and Texas Medicaid guidance where applicable.
No material clinical or coverage changes in this revision.
Coverage criteria and policy scope
Medically Necessary and Not Medically Necessary Indications
Covered when criteria below are met or when corresponding Medicare/Medicaid NCD/LCD/TMPPM criteria apply:
Follow applicable Medicare NCD/LCD or Texas Medicaid TMPPM criteria when present.
Transcatheter aortic valve replacement (TAVR/TAVI) is covered only for FDA‑approved indications and when applicable Medicare or Medicaid NCD/LCD/TMPPM criteria apply. TAVR is considered experimental, investigational and/or unproven for all other indications beyond FDA‑approved uses and those covered by Medicare NCD/LCD criteria.
Transcatheter pulmonary valve implantation (TPVI) may be medically necessary for members with prior repair of congenital heart disease and right ventricular outflow tract dysfunction who are not good candidates for open repair because of multiple prior thoracotomies or high surgical risk from comorbidities. TPVI is considered experimental, investigational and/or unproven for all other indications.
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