Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-93
Topic: Percutaneous (Transluminal) Balloon Valvuloplasty
Effective Date: January 12, 2009
Issued Date: February 8, 2010
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Percutaneous balloon valvuloplasty of the aortic valve is recognized as an eligible surgical procedure in the treatment of congenital aortic stenosis. 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. Percutaneous transluminal balloon valvuloplasty for aortic stenosis is eligible for payment in adults who are poor candidates for aortic valve replacement surgery.

Percutaneous balloon valvuloplasty of the mitral valve 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.

Treatment for any other conditions of either the aortic valve or the mitral 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 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

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.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

For CPT code 92986:

424.1746.3  

For CPT code 92987:

394.0394.2396.0396.1

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.