Have you been told you need surgery to correct your aortic stenosis and wondered if you’ll be able to afford it? Aortic stenosis is a condition that occurs when the heart’s aortic valve starts to narrow, reducing or completely blocking blood flow from your heart to the rest of your body. Many people who require treatment for their aortic stenosis have Medicare, the federal health insurance program for people over 65. If you fall into this group, there’s good news. Medicare covers transcather aortic valve replacement (TAVR), a minimally invasive procedure to repair a narrowed aortic valve, as long as certain criteria are met. Understanding TAVR as a Treatment for Aortic Stenosis Traditionally, aortic stenosis was treated with open heart surgery. But if you’re considered an intermediate to high risk for complications from open heart surgery, you may be a candidate for TAVR instead. In this procedure, a long, thin tube called a catheter is inserted through an artery in your groin or small incision in your neck or chest. The catheter is used to guide a new heart valve to the area of the aortic valve. Once properly situated, the new valve expands over the diseased valve and begins to function in its place. TAVR not only benefits patients who cannot safely undergo open heart surgery, but it also results in fewer complications, shorter hospitalizations and quicker recovery than traditional surgical valve repair. Requirements for Medicare Coverage for TAVR When it comes to getting coverage for TAVR, the Centers for Medicare and Medicaid Services (CMS) require the following conditions to be fulfilled in order to cover the procedure: You must have symptomatic aortic stenosis. The replacement aortic valve and system used to implant it must be approved by the Food and Drug Administration (FDA). You must have met with two cardiac surgeons, who both independently agree you’re a good candidate for TAVR. You must be under the care of a heart team both before and after surgery. The heart team should be made up of different medical professionals, including an interventional cardiologist and a cardiac surgeon. An interventional cardiologist is specially trained to perform catheter-related procedures, and will work alongside your regular cardiologist. Your heart team and the hospital in which it operates have to meet certain criteria, including performing a designated number of various medical procedures per year. Your heart team and hospital must participate in a national registry that tracks the outcome of TAVR patients. In some cases, even if some of the above criteria aren’t met, Medicare will cover a TAVR procedure if it’s performed as part of a clinical trial. But that clinical trial must meet specific criteria as well. If for some reason Medicare will not cover your TAVR procedure, ask your doctor if a clinical trial might be a good option. Possible Changes to Medicare Coverage for TAVR These requirements for Medicare coverage have been in place since 2012 when TAVR was first approved by CMS. However, there has been some concern that the current policy is too restrictive and is limiting potential patients’ access to TAVR. As a result, CMS is reconsidering what will be required for Medicare to cover TAVR, and the new policy is expected to be published by June 25, 2019. Whether this actually will widen or limit access to TAVR is still unknown at this time. Navigating your health insurance can be confusing, especially when changes are made to your coverage. But surgery can be expensive, so it’s important you understand what your insurance will cover versus what you have to pay out of pocket. Whether you are relying on Medicare or private health insurance to help pay for your aortic stenosis treatment, don’t be afraid to ask questions or get clarifications regarding your benefits.