Transcatheter Mitral Valve Repair Medical Policy
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This policy governs prior authorization and medical-necessity review for transcatheter mitral valve repair, including transcatheter edge-to-edge repair (TEER), transcatheter mitral valve clips, and percutaneous mitral valve repair for Commercial, Medicare Advantage, and Medicaid members.
Medicare coverage review now references InterQual criteria for TEER under the mitral valve regurgitation NCD, CED Study, and Clinical Trial pathways.
Requests for members younger than 18 years are reviewed on a case-by-case basis.
Transcatheter mitral valve repair for indications outside the adopted criteria is considered not medically necessary.
Medical Necessity and Coverage Criteria
Commercial and Medicaid Criteria
Commercial and Medicaid (BeHealthy) requests are reviewed using adopted InterQual criteria.
Commercial or Medicaid TEER review
- The request must be reviewed under InterQual CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER).
Applies to transcatheter mitral valve repair, transcatheter edge-to-edge mitral valve clip, and percutaneous mitral valve repair. The detailed InterQual clinical criteria are not reproduced in this policy.
Medicare Criteria
Medicare requests are reviewed using the adopted Medicare InterQual criteria.
Medicare TEER review pathway
- The request must be evaluated under Medicare: Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) CED Study.
- The request must be evaluated under Medicare: Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) Clinical Trial.
Pediatric Case-by-Case Review
Members under 18 years of age are reviewed individually.
No standard pediatric criteria are specified.
Indications Outside Criteria
Coverage is limited to indications addressed by the adopted criteria.
Transcatheter mitral valve repair, transcatheter edge-to-edge mitral valve clip, and percutaneous mitral valve repair for all other indications are considered not medically necessary.
Coverage review applies to transcatheter mitral valve repair (TMVr), including transcatheter edge-to-edge mitral valve clip and percutaneous mitral valve repair. Commercial and Medicaid requests are evaluated under the adopted InterQual criteria for Transcatheter Mitral Valve Edge-to-Edge Repair (TEER). Medicare requests are evaluated under the applicable adopted Medicare InterQual pathway for TEER for mitral valve regurgitation, including the NCD, CED Study, or Clinical Trial pathway.
Requests for members under 18 years of age are reviewed on a case-by-case basis because standard pediatric criteria are not specified. Coverage is limited to indications addressed by the applicable adopted criteria.
TMVr, transcatheter edge-to-edge mitral valve clip, and percutaneous mitral valve repair requested for indications other than those addressed by the adopted Commercial, Medicaid, or Medicare criteria are considered not medically necessary.
Procedure Codes
| 33418 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. |
| 33419 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure). |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus. |
Prior Authorization and Submission Requirements
Use the applicable line-of-business criteria
Apply the criteria for the member’s line of business when submitting a request. Commercial and Medicaid (BeHealthy) requests use the adopted InterQual criteria for Transcatheter Mitral Valve Edge-to-Edge Repair (TEER); Medicare requests use the adopted Medicare InterQual criteria for the applicable NCD, CED Study, or Clinical Trial pathway.
- Commercial and Medicaid: CP: Procedures: Transcatheter Mitral Valve Edge-to-Edge Repair (TEER)
- Medicare: TEER for Mitral Valve Regurgitation NCD, TEER CED Study, or TEER Clinical Trial
Submit pediatric requests for individual review
Requests for members under 18 years of age must be submitted for case-by-case review because the policy does not specify standard pediatric criteria.
Submit clinical evidence with the request
The treating physician or primary care provider must submit clinical evidence to Health New England showing that the patient meets the criteria for the treatment, testing, or surgical procedure when requesting prior authorization.
Avoid indications outside adopted criteria
Requests for transcatheter mitral valve repair, transcatheter edge-to-edge mitral valve clip, or percutaneous mitral valve repair for indications outside the adopted Commercial, Medicaid, or Medicare criteria are considered not medically necessary.
Provide adequate documentation for review
Health New England cannot properly review a prior-authorization request without clinical evidence and documentation showing that the member meets the treatment criteria. Submit the required clinical information with the request to avoid an incomplete review.
Clinical Background
Mitral valve transcatheter edge-to-edge repair (TEER) treats mitral regurgitation by clipping together a portion of the mitral valve leaflets. The intended effects are to reduce mitral regurgitation and cardiac workload, improve heart function, and potentially halt progression of heart failure.
Key Terms
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