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CurrentCurativePolicy CHP-IP-2026-135

Aortic Root Replacement (Bentall Procedure)

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Governs medical necessity and inpatient level-of-care criteria for composite aortic root replacement and valve-sparing root replacement in adults, including elective and emergent cases such as acute type A dissection involving the root. Pediatric and congenital cases require physician review; isolated aortic valve replacement and transcatheter procedures are reviewed under the valve policy.

Policy Summary

PayerCurative

PolicyAortic Root Replacement (Bentall Procedure)

Policy CodePolicy CHP-IP-2026-135

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument that all inpatient admission criteria are met, including a qualifying procedure indication and inpatient setting requirement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.5 cmSporadic root aneurysm surgical threshold

4.5 cmThreshold with concurrent valve surgery

5–8 daysExpected elective length of stay

48 hoursContinued-stay review interval

100 mL/hMediastinal bleeding threshold

AdultsPrimary population

Medical Necessity and Level-of-Care Criteria

Inpatient admission

Covered when ALL of the following are met:

Inpatient admission for aortic root replacement

Procedure indications met
- At least one qualifying indication
  - Acute aortic dissection involving the ascending aorta or root (type A).
  - Sporadic root aneurysm measuring at least 5.5 cm, or at least 5.0 cm in a low-risk patient at a center with a Multidisciplinary Aortic Team.>= 5.5 cm; or >= 5.0 cm when low risk and treated at a center with a Multidisciplinary Aortic Team
  - Marfan syndrome with a root measuring at least 5.0 cm, or at least 4.5 cm with dissection-risk features, or a root area-to-height ratio of at least 10 cm2/m.

Policy Summary

PayerCurative

PolicyAortic Root Replacement (Bentall Procedure)

Policy CodePolicy CHP-IP-2026-135

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument that all inpatient admission criteria are met, including a qualifying procedure indication and inpatient setting requirement.

SourceLink

On This Page

>= 5.0 cm; or >= 4.5 cm with dissection-risk features; or >= 10 cm2/m

Other heritable thoracic aortic disease, such as Loeys-Dietz syndrome, at the gene-specific guideline threshold.

Bicuspid aortic valve with a root measuring at least 5.5 cm, or at least 5.0 cm with risk factors or low surgical risk.>= 5.5 cm; or >= 5.0 cm with risk factors or low surgical risk

Aortic growth of at least 0.5 cm in 1 year for sporadic disease or at least 0.3 cm in 1 year for heritable thoracic aortic disease or bicuspid aortic valve.>= 0.5 cm/year for sporadic disease; or >= 0.3 cm/year for heritable disease or bicuspid aortic valve

Aortic valve disease meeting surgical criteria with a root or ascending aortic diameter of at least 4.5 cm.>= 4.5 cm

Symptoms attributable to the aneurysm, root involvement by endocarditis, or pseudoaneurysm.

Inpatient setting required

Open cardiac surgery with cardiopulmonary bypass and planned postoperative ICU care.
This requirement is always met for the described open procedure.

Observation or outpatient management

Outpatient surveillance applies when the aneurysm is below the surgical threshold:

Surveillance instead of inpatient root replacement

The aneurysm is below the surgical threshold, without symptoms, rapid growth, or a valve indication.
Use outpatient imaging surveillance. Observation and outpatient care do not apply to open aortic root replacement.

Intensive care unit

ICU care is appropriate when ANY of the following is present:

Intensive care criteria

Immediate postoperative period after open cardiac surgery, typically the first 12 to 24 hours.
Mechanical ventilation, vasopressor or inotrope requirement, or mechanical circulatory support, including IABP, percutaneous VAD, or ECMO.
Mediastinal bleeding above 100 mL/h or tamponade physiology.> 100 mL/h
Arrhythmia with hemodynamic compromise requiring IV titration or pacing.

Step-down or intermediate care

Step-down care is appropriate when ANY of the following is present and ICU criteria are not met:

Step-down or intermediate care criteria

The patient is extubated and off vasopressors, with chest tubes or epicardial pacing wires requiring continuous telemetry.
New atrial fibrillation requiring IV rate control or initiation of anticoagulation.
Weaning a low-dose inotrope or IV vasodilator.

Medical-surgical unit

A telemetry-capable medical-surgical bed is appropriate when ANY of the following applies and higher-level criteria are not met:

Medical-surgical unit criteria

Chest tubes have decreasing output, pacing wires have been removed, and the patient is ambulating with assistance.
Diuresis and transition to oral medicines are in progress.

Discharge readiness

Discharge is appropriate when ALL of the following are met:

Hemodynamically stable on oral medicines, with heart rate and blood pressure at target.
Chest tubes and pacing wires have been removed, with no significant pericardial effusion.
Anticoagulation is in range for a mechanical valve, or a bridging plan is established.
Ambulating, tolerating diet, and pain is controlled on oral medicines.
Sternal precautions have been taught, cardiac rehabilitation referral has been arranged, and surgical follow-up within 2 weeks has been arranged.

Continued stay

Continued stay is medically necessary, with review every 48 hours, when ANY of the following is documented:

Continued-stay criteria

Bleeding, effusion, or tamponade requiring intervention.
Atrial fibrillation requiring IV therapy or initiation of anticoagulation.
Respiratory failure requiring ventilation beyond 48 hours.> 48 hours
Acute kidney injury requiring dialysis.
Stroke under evaluation.
Inotrope or vasopressor needs beyond 72 hours.> 72 hours
Sternal wound infection requiring IV antibiotics or debridement.

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review:

Asymptomatic sporadic root aneurysm below 5.0 cm without growth, heritable thoracic aortic disease, or a valve indication.
Below the guideline threshold; surveillance is appropriate.
Pre-operative inpatient days for an elective case without a medical need.
Elective preparation is outpatient.
Continued stay after discharge criteria are met while awaiting placement without an acute need.
Route to discharge planning.

Isolated aortic valve replacement and transcatheter procedures are outside the scope of this policy. Review these services under the applicable valve policy.

Observation and outpatient care do not apply to open aortic root replacement. However, surveillance imaging for aneurysms below the surgical threshold is performed on an outpatient basis.

An asymptomatic sporadic root aneurysm below 5.0 cm without documented growth, heritable thoracic aortic disease, or a valve indication does not meet medical-necessity criteria; surveillance is appropriate.

Pre-operative inpatient days for an elective case do not meet medical-necessity criteria when there is no medical need for inpatient care, because elective preparation is outpatient.

A continued inpatient stay after discharge criteria are met does not meet medical-necessity criteria when the patient is only awaiting placement and has no acute medical need. These cases should be routed to discharge planning.

Related Diagnosis, Procedure, and Threshold Coding

ICD-10-CM thoracic aortic aneurysm, dissection, and ectasiaICD-10

I71.11	thoracic aortic aneurysm (ascending), dissection, ectasia
I71.21	thoracic aortic aneurysm (ascending), dissection, ectasia
I71.010	thoracic aortic aneurysm (ascending), dissection, ectasia
I77.810	thoracic aortic aneurysm (ascending), dissection, ectasia

ICD-10-CM aortic valve disease and related congenital or genetic conditionsICD-10

I35.0	aortic valve disease and related congenital or genetic conditions
I35.1	aortic valve disease and related congenital or genetic conditions
I35.2	aortic valve disease and related congenital or genetic conditions
Q23.0	aortic valve disease and related congenital or genetic conditions
Q87.410	aortic valve disease and related congenital or genetic conditions

ICD-10-PCS replacement of aortic valve and ascending aortaICD-10

02RF08N	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RF08Z	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RF0JZ	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RF0KZ	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RX07Z	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RX08Z	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RX0JZ	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RX0KZ	replacement of aortic valve and ascending aorta (complete 7-character codes required)
02RF07Z	replacement of aortic valve and ascending aorta (complete 7-character codes required)

CPT ascending aorta graft and aortic root replacementCPT

33858	ascending aorta graft and aortic root replacement
33859	ascending aorta graft and aortic root replacement
33863	ascending aorta graft and aortic root replacement
33864	ascending aorta graft and aortic root replacement

MS-DRG FY2027 v44MS-DRG

216	cardiac valve and other major cardiothoracic procedures
217	cardiac valve and other major cardiothoracic procedures
218	cardiac valve and other major cardiothoracic procedures
219	cardiac valve and other major cardiothoracic procedures
220	cardiac valve and other major cardiothoracic procedures
221	cardiac valve and other major cardiothoracic procedures

Revenue codesRevenue

0200	revenue code
0360	revenue code
0270	revenue code

Sporadic root aneurysm

Standard surgical thresholdSporadic root aneurysm measuring 5.5 cm or more

Lower surgical threshold5.0 cm or more in a low-risk patient

Lower-threshold pathwayThe 5.0 cm threshold applies at a center with a Multidisciplinary Aortic Team

Marfan syndrome root diameter

Standard root diameterMarfan syndrome with a root diameter of 5.0 cm or more

Dissection-risk threshold4.5 cm or more when dissection risk features are present

Applicable conditionThe thresholds apply to aortic root replacement for Marfan syndrome

Marfan root area-to-height ratio

Area-to-height thresholdRoot area-to-height ratio of 10 cm2/m or more

Measurement typeAortic root area-to-height ratio

Applicable conditionThe threshold is an additional Marfan syndrome root criterion

Bicuspid aortic valve root diameter

Standard root diameterBicuspid aortic valve with a root diameter of 5.5 cm or more

Risk-factor threshold5.0 cm or more with risk factors

Low-risk threshold5.0 cm or more in a patient with low surgical risk

Aortic growth

Sporadic diseaseGrowth of 0.5 cm or more in 1 year

Heritable thoracic aortic diseaseGrowth of 0.3 cm or more in 1 year

Bicuspid aortic valveGrowth of 0.3 cm or more in 1 year

Concurrent valve surgery root or ascending diameter

Diameter thresholdRoot or ascending aortic diameter of 4.5 cm or more

Surgical contextAortic valve disease must meet surgical criteria

Concurrent procedureThe threshold applies when aortic valve surgery is indicated

Authorization and Documentation Requirements

Prior Authorization

Document Qualifying Indication and Inpatient Setting

Document that the request meets a qualifying indication for aortic root replacement and that the procedure requires an inpatient setting. The record must support both the applicable procedure indication and inpatient admission, including open cardiac surgery with cardiopulmonary bypass and planned postoperative ICU care.

Qualifying indications may include acute type A dissection; aneurysm meeting the applicable diameter threshold; HTAD, bicuspid valve, or growth criteria; qualifying aortic valve disease; symptoms attributable to the aneurysm; or root involvement by endocarditis or pseudoaneurysm.
Document the inpatient requirement and planned postoperative ICU care.

Billing Rule

Authorize Only the Supported Duration

Approve the supported portion when the service meets criteria but the requested quantity, units, or duration exceed what the documentation supports. Refer only the unsupported increment for review; do not deny the supported portion.

Concurrent review applies to each continued-stay period.
Days already authorized are not retroactively denied, and expected length of stay is a planning benchmark rather than a limit on covered days.

Documentation Required

Submit Aortic Imaging and Growth Documentation

Submit current imaging documenting aortic root and ascending-aorta dimensions, together with prior studies when needed to establish interval growth.

Include measurements relevant to the applicable threshold.
Document growth of at least 0.5 cm in 1 year for sporadic disease or 0.3 cm in 1 year for HTAD or bicuspid valve disease, when used as the indication.

Documentation Required

Document HTAD Diagnosis

Document the genetic or syndromic diagnosis when a heritable thoracic aortic disease (HTAD) indication applies.

Identify the applicable HTAD diagnosis, such as Marfan syndrome or another condition including Loeys-Dietz syndrome.
Provide gene-specific threshold documentation when applicable.

Documentation Required

Submit Valve Assessment

Submit an echocardiographic assessment of the aortic valve when valve disease or bicuspid aortic valve status is relevant to the request.

Include valve morphology and clinically relevant valve disease findings.
Document when aortic valve disease meets surgical criteria with a root or ascending-aorta diameter of at least 4.5 cm.

Documentation Required

Document Surgical Risk Assessment

Document the patient's surgical risk assessment when using a lower diameter threshold that depends on low surgical risk.

Identify the patient's risk classification and supporting clinical factors.
For sporadic root aneurysm, document low-risk status when relying on a threshold of 5.0 cm or more at a center with a Multidisciplinary Aortic Team; for bicuspid aortic valve, document low surgical risk when applicable.

Denial Risk

Below-Threshold Asymptomatic Aneurysm

An asymptomatic sporadic root aneurysm below 5.0 cm, without documented growth, HTAD, or a valve indication, does not meet medical-necessity criteria under this policy. Surveillance is appropriate, and the request is referred for physician review.

Do not treat an aneurysm below the guideline threshold as qualifying without a documented modifier or other indication.

Denial Risk

Unnecessary Pre-Operative Inpatient Stay

Pre-operative inpatient days for an elective case do not meet criteria when there is no medical need for inpatient preparation. Elective preparation should occur in the outpatient setting.

Document an acute medical need if inpatient days before surgery are requested.

Denial Risk

Continued Stay After Discharge Readiness

A continued inpatient stay after discharge criteria are met does not meet criteria when the patient is only awaiting placement and has no acute medical need. Route the case to discharge planning.

Support each continued-stay period with an active acute inpatient need.
Placement barriers alone do not justify continued hospitalization.

Prior Authorization

Physician Review Required for Adverse Determinations

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination. Requests that do not meet criteria, including unsupported increments, must be referred for physician review.

Only a licensed physician of the same or similar specialty may issue an adverse determination.
The reviewing physician must offer the requesting provider a peer-to-peer discussion and meet applicable licensure, specialty, and medical-director requirements.

Policy Scope and Clinical Context

This policy addresses the medical necessity and inpatient management of composite aortic root replacement (Bentall procedure) and valve-sparing root replacement in adults. Covered indications may include aneurysm, heritable aortopathy, bicuspid valve-associated disease, rapid aortic growth, valve disease with root involvement, attributable symptoms, endocarditis, pseudoaneurysm, and acute type A dissection involving the root. Surgical thresholds vary by clinical context, including generally 5.5 cm for sporadic root or ascending aneurysm and lower thresholds for selected patients with heritable disease, bicuspid aortic valve disease, rapid growth, or concurrent valve surgery.

Key Clinical Definitions

Heritable thoracic aortic disease (HTAD)

DefinitionHeritable thoracic aortic disease (HTAD) is a genetically triggered aortopathy

Syndromic exampleMarfan syndrome

Syndromic examplesLoeys-Dietz syndrome or vascular Ehlers-Danlos syndrome

Familial conditionFamilial aneurysm