Transcatheter Tricuspid Valve Repair or Replacement (T-TEER or TTVR)
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This policy governs coverage determinations for transcatheter tricuspid valve edge-to-edge repair (T-TEER) and transcatheter tricuspid valve replacement (TTVR) for Commercial Products of Blue Cross Blue Shield - Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Determination
Not Medically Necessary (Commercial Products)
Commercial Products coverage determination
Applies to CPT codes 0569T, 0570T, and 0646T as listed in coding section.
This policy applies to Commercial Products of Blue Cross & Blue Shield of Rhode Island. For coverage determinations for Medicare Advantage Plans, refer to the Related Policies section of the full policy document.
Coverage and payment are governed by the member's subscriber agreement, member certificate, or employer agreement and those documents supersede this medical policy. For information on member-specific benefits and prior authorization requirements, providers should contact the provider call center. This policy is informational and is not a guarantee of payment.
For Commercial Products, Transcatheter Tricuspid Valve Edge-to-Edge Repair (T-TEER) and Transcatheter Tricuspid Valve Replacement/Implantation (TTVR/TTVI) are considered not medically necessary. The policy lists the following CPT codes as not medically necessary for Commercial members: 0569T, 0570T, and 0646T.
If a service is determined to be not medically necessary (or is a medically necessary service that is a non-covered benefit under the member's coverage), providers may not charge the member for the service unless the provider has informed the member in advance and the member has agreed in writing to assume financial responsibility for the service.
Coding and Registry Requirements
| 0569T | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis |
| 0570T | Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (List separately in addition to code for primary procedure) |
| 0646T | Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed |
Provider Responsibilities and Billing Impacts
Prior authorization: Not applicable
This policy lists prior authorization as Not applicable; no prior authorization requirement is specified for T-TEER or TTVR in this document.
Verify benefits and prior authorization with provider call center
Verify member-specific benefits and any prior authorization requirements by contacting the provider call center; coverage and payment are governed by the member's subscriber agreement or employer agreement.
Step therapy: Not applicable
Medical criteria are listed as Not applicable; this policy does not establish step therapy requirements for T-TEER or TTVR.
Provider action: Verify benefits and contractual terms
Providers should verify member benefits and eligibility and follow billing and contractual rules; refer to the Evidence of Coverage or Subscriber Agreement for specifics before proceeding.
Benefit verification: Refer to Evidence of Coverage or Subscriber Agreement
Benefits may vary between groups and contracts; refer to the member's Evidence of Coverage or Subscriber Agreement for applicable surgery benefits and coverage determinations.
Benefits and eligibility verification required
Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement; verify member-specific benefits with the provider call center as those documents supersede this medical policy.
Member financial responsibility when service not covered
If a service is determined to be not medically necessary or is a non-covered benefit, do not charge the member unless the member has been informed and has agreed in writing in advance to pay; follow your participation agreement provisions.
Clinical Background
Tricuspid regurgitation (TR) is the backflow of blood across an insufficient tricuspid valve. TR is often secondary to annular dilation and leaflet tethering from right ventricular remodeling related to left-sided heart disease, pulmonary hypertension, or atrial fibrillation. Clinically significant TR is more common in older adults and is associated with increased mortality, recurrent heart failure hospitalizations, and reduced quality of life. Surgical isolated tricuspid interventions are infrequent because of high perioperative risk; transcatheter approaches such as T-TEER and TTVR have emerged as less invasive alternatives under investigation and adoption.
Definitions and Guidance
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