Federal health regulators are moving forward with two distinct policy changes that reshape how Medicare covers a common heart valve procedure and how out-of-network billing disputes are resolved nationwide. The Centers for Medicare & Medicaid Services (CMS) is implementing updated coverage and billing rules for transcatheter aortic valve replacement (TAVR) following its September 10, 2026 final decision, while federal agencies simultaneously revoked the credentials of two independent dispute resolution (IDR) entities under the No Surprises Act on November 4, 2026.

While the two regulatory actions address separate areas of the American healthcare system, both carry immediate operational consequences for hospitals, physicians, insurance payers, and patients navigating cardiac care or unexpected medical bills.

Updated Medicare Coverage Rules for TAVR Procedures

In a regulatory notice issued on November 3, 2026, Medicare administrative contractor CGS Medicare outlined the operational and billing updates stemming from CMS's September 10, 2026 final decision memo revising National Coverage Determination (NCD) 20.32.

The updated policy modifies when and how Medicare pays for TAVR, a minimally invasive procedure used to replace a narrowed aortic valve that fails to open properly.

Under the revised policy, Medicare covers TAVR for patients with symptomatic severe aortic stenosis without the previously required coverage with evidence development (CED) mandate. Removing the CED requirement for symptomatic patients eliminates an administrative layer for facilities and clinicians treating individuals who already display clinical symptoms of severe valve narrowing.

At the same time, the updated NCD expands Medicare coverage to include patients with asymptomatic severe aortic stenosis, though this expansion comes with strict conditions. According to CGS Medicare, asymptomatic severe aortic stenosis is covered only under the CED pathway.

While industry reporting from MedTech Dive notes that the policy shift broadens patient access, the contractor guidance makes clear that asymptomatic patients do not receive unrestricted blanket coverage and must participate in a CMS-approved clinical study.

Beyond patient eligibility, the revised determination updates criteria governing pre-procedural patient assessments, intraoperative protocols, and the procedural volume standards required for both operators and hospitals. For claims with dates of service on or after September 10, 2026, CGS Medicare instructs facilities to use institutional billing through Type of Bill 11X or Place of Service 21. On Part B professional claims, modifier 62 is now required only when the multi-disciplinary heart team determines that joint participation by two surgeons is clinically appropriate. Claims for asymptomatic patients treated within an approved CED study must also include an eight-digit clinical trial identifier and diagnosis code Z00.6.

Although these interim billing rules are active, the contractor noted that a formal change request to update the overarching Medicare manuals remains forthcoming.

Federal Agencies Drop Two No Surprises Act Arbitrators

In a separate enforcement action on November 4, 2026, the Departments of Health and Human Services, Labor, and the Treasury denied recertification to two federal IDR entities: Island Peer Review Organization (IPRO) and Network Medical Review Company. According to the American Hospital Association, the agencies found that both organizations failed to meet minimum federal performance standards required to arbitrate out-of-network payment disputes between healthcare providers and insurers under the No Surprises Act.

As a result of the decision, neither IPRO nor Network Medical Review Company is permitted to accept new federal IDR disputes. According to Becker's Payer Issues, both organizations have 30 business days from the receipt of their written denial notices to appeal the federal decision.

Healthcare providers and health plans that currently have open billing disputes pending before either entity are awaiting further instructions from federal agencies regarding how those cases will be reassigned or resolved.

The specific causes behind the recertification denials remain a subject of differing context across industry reports. Federal officials publicly attributed the removals to failures in meeting minimum performance standards tied to timeliness, accuracy, and independence or impartiality, according to Becker's Payer Issues. However, Healthcare Dive reported that the agencies did not publicly detail the exact operational failures or explain why these two specific entities were singled out, noting that regulators had previously outlined potential grounds for removal in a general FAQ rather than releasing entity-specific findings.

External data has nonetheless drawn scrutiny to arbitration outcomes. Healthcare Dive reported that, based on Turquoise Health data, IPRO held the highest provider win rate among certified arbitrators at about 97%, while Network Medical Review Company sided with healthcare providers about 70% of the time.

Similarly, STAT reported that its investigation found IPRO and other arbitration firms were generating substantial profits while frequently ruling in favor of clinicians. Even so, Healthcare Dive noted that win rates alone do not prove bias or establish the exact basis for the federal agencies' decision. Meanwhile, federal officials continue to review recertification petitions for eight other certified IDR entities.

What These Regulatory Shifts Mean for Patients and Providers

For Medicare beneficiaries living with aortic valve disease, the revised TAVR policy clarifies how treatment is accessed and funded. Patients experiencing symptoms of severe aortic stenosis—such as shortness of breath, chest pain, or fatigue—no longer face the administrative requirement of enrolling in an evidence-development registry for Medicare coverage.

Patients diagnosed with severe aortic stenosis who do not yet show physical symptoms may now qualify for Medicare coverage without waiting for their condition to deteriorate, provided their hospital participates in an approved clinical trial.

For hospitals and health systems, the two federal actions require immediate administrative adjustments. Cardiology departments and billing teams must ensure that TAVR claims dated on or after September 10, 2026 adhere to the updated modifier 62 rules and clinical trial coding protocols, while also verifying that their surgical programs meet the revised operator and institutional volume benchmarks. Simultaneously, hospital revenue cycle teams and health insurers managing out-of-network reimbursement disputes must prepare for potential processing bottlenecks as federal agencies transition open cases away from IPRO and Network Medical Review Company and evaluate the remaining eight arbitration organizations.

Frequently Asked Questions

Does Medicare now cover TAVR for all patients with severe aortic stenosis?

Medicare covers TAVR for patients with symptomatic severe aortic stenosis without requiring coverage with evidence development (CED). However, for patients whose severe aortic stenosis is asymptomatic, Medicare coverage applies only if the procedure is performed within a CMS-approved CED clinical study and billed with the proper eight-digit trial identifier and diagnosis code Z00.6.

How does the removal of the two No Surprises Act arbitrators affect patients?

The No Surprises Act shields patients from unexpected out-of-network balance bills for emergency care and certain scheduled services at in-network facilities. The independent dispute resolution (IDR) process strictly handles payment negotiations between healthcare providers and insurance companies behind the scenes. The removal of the two arbitrators affects how hospitals and insurers settle payment rates, but it does not change the legal protections that keep patients out of those billing disputes.

What happens to open billing disputes currently assigned to IPRO or Network Medical Review Company?

Neither organization is permitted to accept new federal disputes as of November 4, 2026. For disputes that were already open and assigned to IPRO or Network Medical Review Company prior to the denial, the federal agencies stated they will issue additional guidance to the involved providers and health plans outlining next steps and reassignment procedures.

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