Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-93
Topic: Percutaneous (Transluminal) Balloon Valvuloplasty
Effective Date: August 1, 2005
Issued Date: May 15, 2006
Date Last Reviewed: 05/2006

General Policy Guidelines

Indications and Limitations of Coverage

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 is considered experimental/investigational. Scientific evidence does not demonstrate the efficacy of percutaneous balloon valvuloplasty of the aortic valve for any other conditions.

Percutaneous balloon valvuloplasty of the mitral valve (92987) is recognized as an eligible surgical procedure for patients with severe uncomplicated mitral valve stenosis in whom the anatomical features of the valve are favorable.

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.

Procedure Codes

929869298792990   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Percutaneous balloon valvuloplasty of the aortic valve for conditions other than those listed as eligible on the policy is considered eligible when determined medically necessary based on the patient’s condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

08/1995, Mitral balloon valvuloplasty
02/1997, Percutaneous balloon valvuloplasty of the aortic valve
08/2001, Percutaneous balloon valvuloplasty of the aortic valve

References

View Previous Versions

[Version 001 of S-93]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.