If your doctor has recommended that you have a transcatheter procedure for a problem with your heart, it is likely because they believe the procedure will significantly improve your health. Transcatheter procedures are much less invasive than open heart surgery, allowing shorter hospital stays and easier recoveries. Being denied a necessary transcatheter procedure can be devastating, but it is important that you do not give up. You can talk to an attorney like Scott Glovsky, who has spent his career helping people just like you get the treatments they need when an insurance company balks at paying for the procedure. We’ve filed transcatheter cases in the past. You need a strong advocate who will fight for you, and Scott Glovsky is that advocate.
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What are Transcatheter Procedures?
Your doctor may recommend using a catheter—a thin, hollow tube—to repair heart valve damage and disease. This method, known as the transcatheter procedure, is much less invasive than surgery performed by opening the patient’s chest. During a transcatheter procedure, the heart is accessed using a catheter, which is inserted into a blood vessel—usually in the leg. There is generally a decrease in loss of blood, less pain, quicker recovery time, less scarring, a shorter hospital stay, and a lowered risk of infection. The different types of transcatheter procedures include:
- Transcatheter pulmonary valve replacement—When a damaged pulmonary valve in the heart needs to be replaced, the procedure can be done via TPVR without opening the chest. The pulmonary valve controls blood flow from the lower right chamber of the heart to the lungs. A damaged pulmonary valve can slow blood flow, leading to heart failure. Adults with congenital heart disease who had a pulmonary valve replacement procedure as a child will often undergo TPVR.
- Transcatheter aortic valve replacement—A procedure that replaces a narrowed aortic valve that is not opening fully is known as a transcatheter aortic valve replacement, or TAVR. The aortic valve is located between the left chamber of the lower heart and the main artery in the body. When the valve fails to open fully, blood flow from the heart to the body slows down, potentially causing heart failure. TAVR uses small incisions, so it is minimally invasive. Chest pain, shortness of breath and other aortic valve stenosis symptoms can be reduced or relieved through a TAVR.
- Transcatheter aortic valve implantation—This is a minimally invasive procedure that replaces a malfunctioning or diseased aortic valve with a new one made from animal tissue. The catheter is guided through a blood vessel in the groin or chest to the aortic valve in the heart. The folded replacement valve is sent through the catheter and then expanded by a balloon on the top of the catheter. The catheter is removed, and the surgeon checks for any complications or leakage of the new valve. TAVI may be used for older or frail individuals, those with a weak heart or a history of stroke, those who have had prior heart surgeries, individuals with COPD, liver disease, kidney disease, diabetes, previous radiation to the chest, or large calcium deposits in the ascending aorta.
- Transcatheter mitral valve repair—The mitral valve in the heart controls blood flow between the lower left heart chamber and the upper left heart chamber (the ventricle to the atrium). When a mitral valve is not functioning properly, it can result in heart failure, irregular heart rhythm, or pressure buildup in the left atrium. During TMVR, a catheter is inserted through a blood vessel to reach the heart and replace the mitral valve.
- MitraClip—A MitraClip repairs a leaky heart valve which renders the heart unable to pump enough blood to meet the demands of the body. Symptoms of a leaky heart valve include shortness of breath, fatigue, dry hacking cough, excessive urination, fainting, swollen feet or ankles, and an inability to exercise. If left untreated, as many as 57 percent of those with a leaky heart valve may not survive a year. The MitraClip is a relatively simple procedure that fixes the mitral valve. The catheter is threaded through a vein in the leg to the heart. A small clip is then attached to the mitral valve to help it close fully, restoring normal blood flow to the heart.
- Transcatheter tricuspid valve repair—Known as TTVR, this is a minimally invasive procedure to replace a malfunctioning or damaged heart valve with an artificial one. Tricuspid regurgitation is a condition where the valve fails to close fully, allowing blood to leak backward into the atrium, forcing the heart to pump harder, and causing symptoms like an enlarged liver, extreme fatigue, and swelling. The TTVR can repair tricuspid regurgitation.
Why Would a Transcatheter Procedure Be Denied by Insurance?
The average total hospital cost for a TAVR is about $60,000. Insurance companies sometimes do not want to pay for a transcatheter procedure, so they will look for any excuse to issue a transcatheter procedure insurance denial. The insurance company may issue a letter of denial that states the procedure is not medically necessary or that it is experimental or investigational. If you receive such a letter, it is crucial that you speak to an experienced attorney who will work hard to get your transcatheter procedure approved.
What Should You Do After Receiving a Transcatheter Procedure Insurance Denial?
After receiving a transcatheter procedure insurance denial, your attorney can guide you to immediately file an internal appeal. This appeal asks your insurer to take another look at the request. A letter from your doctor may be included that further details why you need this procedure and why it is medically necessary. If the insurer still denies the transcatheter procedure, your attorney may advise you to file an external appeal or to move forward with a lawsuit. Advice depends on your specific type of insurance, and whether it is ERISA or non-ERISA. If you file an external appeal with a neutral third party, then the decision of the third party is final, and your insurer must abide by the decision.
What Insurance Companies Are Known to Deny Transcatheter Procedures?
While any insurance company can deny a transcatheter procedure, some are more likely to do so than others. In fact, as of 2024, Anthem Blue Cross considers some transcatheter procedures as not medically necessary. California insurance companies in addition to Anthem that could deny such a procedure include:
- Anthem Blue Cross
- Blue Shield
- Health Net
- Kaiser
- United Healthcare
- Aetna
- Medi-Cal Managed Care Plans (Anthem Blue Cross, Promise Health Plan, Health Net, Molina)
How the Law Offices of Scott Glovsky Can Help with Transcatheter Procedure Insurance Denial
At the Law Offices of Scott Glovsky, our mission is to help those who have been wronged by a big insurance company. We care about each client and their cause. We are responsible, supportive, and honest and treat our clients with dignity and respect. Attorney Scott Glovsky worked for large corporate law firms defending big insurance companies early in his career. Because of this, he understands how they think and operate, allowing him always to stay a step ahead of their legal strategy. Scott and his legal team take fewer cases so that each client receives a tremendous amount of time and care throughout the process. Contact the Law Offices of Scott Glovsky today.