Transcatheter Procedures for Heart Valve Conditions (for Ohio Only)
Ohio-only medical policy governing coverage and medical necessity criteria for transcatheter procedures addressing aortic, mitral, tricuspid, and pulmonary valve conditions; applies to UnitedHealthcare decisions in Ohio and references InterQual criteria where noted.
Replaced case-by-case language for low-flow/low-gradient aortic stenosis requests to reference evaluation against InterQual® criteria.
Added language that transcatheter edge-to-edge repair of the tricuspid valve is proven and medically necessary when used per FDA labeling and specific clinical criteria are met (symptomatic severe TR; stable ≥30 days GDMT; NYHA II+; PASP <70 mmHg; intermediate or greater surgical risk determined by a local heart team).
Replaced statement that all transcatheter tricuspid heart valve repair, reconstruction, or replacement is unproven with a narrower statement that reconstruction or replacement is unproven and not medically necessary.
Added requirements and clarifications about medical records documentation that may be required to assess clinical criteria and support medical necessity.
Added definition of 'Symptomatic Severe Tricuspid Regurgitation'.
Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information and archived prior version CS123OH.D.
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