Transcatheter Aortic Valve Implantation — CPB 0826 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0826 governing TAVI coverage policy, effective December 5, 2025. Billing teams need to review medical necessity criteria across CPT codes 33361–33369 and 93590–93592 before submitting claims.

Quick-Reference Table

Aetna TAVI Coverage Criteria and Medical Necessity Requirements 2025

The CPB 0826 Aetna TAVI coverage policy covers three distinct patient populations. Each one has hard clinical criteria. If your documentation doesn't match the criteria exactly, you're looking at a claim denial.

Population 1: Inoperable patients. TAVI using an FDA-approved valve — Edwards Sapien 3, Edwards Sapien XT, Edwards Sapien transcatheter heart valve, or Medtronic CoreValve System — is medically necessary for patients with severe symptomatic calcified native aortic valve stenosis. The patient must have an ejection fraction greater than 20%, no severe aortic insufficiency, and be inoperable for open aortic valve replacement. Existing comorbidities must not block the expected benefit.

Population 2: High-risk surgical candidates and low-risk patients. This population has two subgroups, and both must be met as written in the policy. The first subgroup covers patients who are surgical candidates with a Society of Thoracic Surgeons (STS) operative risk score of 8% or higher — or a 15% or greater mortality risk for surgical aortic valve replacement. These patients must have severe symptomatic calcified native aortic valve stenosis, ejection fraction above 20%, and no severe aortic insufficiency. The second subgroup covers patients with aortic valve stenosis who are determined to be at low risk for death or complications from open-heart surgery. The policy links these two subgroups with an "and" conjunction — read the criteria together, not independently, when documenting coverage eligibility.

Population 3: Valve-in-valve. TAVI using the Medtronic CoreValve System or Sapien 3 is covered for valve-in-valve replacement in patients with a degenerated bioprosthetic aortic valve. The patient must still meet the STS threshold — 8% or greater operative risk, or 15% or greater mortality risk for surgical replacement.

Paravalvular leak repair. Percutaneous repair of prosthetic paravalvular leak (CPT 93590, 93591, 93592) is covered when all four conditions are met: the patient has intractable hemolysis or NYHA class III or IV symptoms, is at high or prohibitive surgical risk, has anatomic features suitable for catheter-based therapy, and the procedure is performed at a comprehensive valve center. Every condition is required. Missing one is a denial.

Aetna TAVI Exclusions and Non-Covered Indications

Eight specific indications are classified as experimental, investigational, or unproven under CPB 0826 Aetna. These are flat denials — document them, train your team on them, and stop submitting claims for them without a clinical justification strategy in place.

BASILICA procedure (CPT 33370). Bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction is not covered. CPT 33370 is listed under the experimental bucket for this procedure. If your structural heart program is doing these, this is a significant revenue exposure point.

Combined TAVI and left atrial appendage occlusion. Aetna doesn't cover the combination. If your team is bundling these, split the claim and document each procedure independently — but know the LAA occlusion may trigger its own coverage policy review under CPB 0791.

TAVI with pre-implantation balloon aortic valvuloplasty. The standalone balloon valvuloplasty (CPT 92986) is listed as a related code, but TAVI combined with pre-implantation BAV is experimental under this policy. Don't bill 33361–33369 alongside 92986 as a staged or combined approach without a strong clinical documentation strategy.

Embolic protection devices during TAVI. Aetna considers use of embolic protection devices during TAVI experimental under this policy. Expect denial. Note: CPB 0826 lists CPT 33370 under the BASILICA procedure group — the policy does not explicitly assign 33370 as the billing code for embolic protection devices. Talk to your billing consultant about how to handle code assignment for this service.

Specific patient populations. TAVI is not covered for patients with ongoing sepsis including endocarditis, bicuspid aortic stenosis, native aortic valve regurgitation, or porcelain aorta. The ICD-10 codes for sepsis (A40.0–A40.9, A41.1–A41.9), endocarditis (I33.0–I33.9), and porcelain aorta (I70.0) are listed in the policy — not as covered codes, but as documentation anchors. Seeing these on a claim will trigger scrutiny.

Biomarker and CO2 gap monitoring. Plasma nitric oxide pathway molecules for predicting post-TAVI cardiac events and CO2 gap as a prognostic marker are both experimental. Urinary biomarkers for detecting acute kidney injury after TAVI (see N17.x codes) are also not covered for this purpose.

Coverage Indications at a Glance

Aetna TAVI Billing Guidelines and Action Items 2025

This policy has real teeth on the exclusions side. The eight experimental designations each carry CPT or ICD-10 exposure your team may not have flagged yet.

CPT, HCPCS, and ICD-10 Codes for TAVI Under CPB 0826

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Key ICD-10-CM Diagnosis Codes