Percutaneous balloon valvuloplasty of the aortic valve (92986) is recognized as an eligible surgical procedure in the treatment of congenital aortic stenosis (746.3). This procedure is most commonly performed on neonates, infants, children, and young adults. It is also recognized in the treatment of patients with calcified valves (424.1). Percutaneous transluminal balloon valvuloplasty for aortic stenosis is eligible for payment in adults who are poor candidates for aortic valve replacement surgery. Treatment for any other conditions of the aortic valve is considered not medically necessary. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Percutaneous balloon valvuloplasty of the mitral valve (92987) is recognized as an eligible surgical procedure for patients with severe uncomplicated mitral valve stenosis (394.0, 394.2, 396.0, 396.1) in whom the anatomical features of the valve are favorable. Treatment for any other conditions of the mitral valve is considered not medically necessary. Participating, preferred, and network providers cannot bill the member for the denied service.

Percutaneous balloon valvuloplasty of the pulmonary valve (92990) is recognized as an eligible surgical procedure.

Description

The technique of percutaneous balloon valvuloplasty involves the percutaneous insertion of one or more large balloons into the aortic, mitral, or pulmonary valve. The balloons are then inflated across the stenotic valve in order to decrease the degree of obstruction within the valve.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Percutaneous balloon mitral valvuloplasty in patients with mitral restenosis after previous surgical commissurotomy, European Heart Journal, 1996

One year outcome of cardioversion of atrial fibrillation in patients with mitral stenosis after percutaneous balloon mitral valvuloplasty, American Journal of Cardiology, Vol. 97, No. 7, 04/2006

Comparison of long-term outcome after mitral valve replacement or repeated balloon mitral valvotomy in patients with restenosis after previous balloon valvotomy, American Journal of Cardiology, Vol. 99, No. 11, 06/2007

Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation, Circulation, Vol. 116, 09/2007