TAVR is a minimally invasive procedure used to treat severe aortic stenosis, a condition where the heart’s aortic valve narrows and restricts blood flow. Historically, treating this condition required open-heart surgery, but TAVR offers a less invasive alternative by implanting a new valve via a catheter, often inserted through a small incision in the leg. Medicare does cover the TAVR procedure, but this coverage is strictly governed by specific requirements established by the Centers for Medicare & Medicaid Services (CMS).
Original Medicare Coverage (Parts A and B)
Original Medicare, which is composed of Part A (Hospital Insurance) and Part B (Medical Insurance), provides coverage for the TAVR procedure. Coverage is divided between these two parts based on the type of service rendered during the hospital stay. This distinction dictates which costs the patient is responsible for.
Medicare Part A covers the facility charges, including the inpatient hospital stay, the operating room, general nursing care, and other institutional costs. Since TAVR is typically designated as an inpatient procedure, Part A coverage is activated upon formal admission to the hospital.
Medicare Part B covers the professional services, which include the physician fees for the surgical team, the interventional cardiologist, and other medical specialists involved in the procedure. Part B also covers the costs of the actual prosthetic heart valve device itself.
National Coverage Determination Requirements
Coverage for TAVR is contingent upon meeting a National Coverage Determination (NCD 20.33) put forth by CMS. This determination ensures the procedure is performed safely and effectively by experienced providers and facilities. A core requirement is that the procedure must be performed at a hospital with an established, comprehensive heart valve program that meets specific volume and structural standards.
The NCD mandates a rigorous, multidisciplinary evaluation process known as the “Heart Team” approach for every patient considered for TAVR. This team must include a cardiac surgeon and an interventional cardiologist, along with other specialists, who jointly determine that the patient is an appropriate candidate for the procedure. The team must conclude that the patient is at intermediate or high risk for traditional surgical aortic valve replacement (SAVR), or otherwise ineligible for SAVR, for the TAVR procedure to be covered.
Facilities must also participate in a CMS-approved national registry to track and submit patient outcomes, which is a condition of coverage under the NCD. This registry, such as the STS/ACC Transcatheter Valve Therapy (TVT) Registry, collects data to monitor the ongoing safety and effectiveness of the TAVR technology. Failure by the hospital or the physician team to adhere to any of these NCD criteria, including the Heart Team evaluation or the registry submission, can result in the denial of Medicare coverage.
Patient Financial Responsibility
Even with Medicare approval, the beneficiary is responsible for certain out-of-pocket costs under Original Medicare. These costs are structured around the deductibles and coinsurance for both Part A and Part B. For the inpatient hospital stay covered by Part A, the patient must pay a deductible, which is \(1,632 per benefit period in 2024.
Once the Part A deductible is satisfied, the patient generally has no further coinsurance liability for the first 60 days of the inpatient stay. For the services covered under Part B, such as physician fees and the valve itself, the patient must first satisfy the annual Part B deductible (\)240 in 2024). After this deductible is met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for all Part B services related to the procedure.
A hospital stay initially designated as observation status rather than a formal inpatient admission can complicate the financial picture. Observation status would shift the facility charges from Part A to Part B, potentially increasing the patient’s coinsurance liability. Patients should always confirm their official admission status.
The Role of Medicare Advantage (Part C)
Patients enrolled in a Medicare Advantage (Part C) plan receive their Medicare benefits through a private insurance company. These plans are required by law to cover all services that Original Medicare covers, including the TAVR procedure. The strict coverage criteria set forth in the National Coverage Determination (NCD) still apply, as Medicare Advantage plans cannot impose more restrictive clinical requirements.
The cost-sharing structure for TAVR under a Medicare Advantage plan will differ significantly from Original Medicare. Instead of the Part A and Part B deductibles and coinsurance, patients typically pay a series of fixed copayments or a percentage coinsurance that is specific to their plan. Furthermore, virtually all Medicare Advantage plans require prior authorization from the plan before the TAVR procedure can be performed. Patients must review their specific plan documents to understand their financial responsibility and to ensure their hospital and physician team are within the plan’s provider network.