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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that failed conservative management of CVD may include the need for Percutaneous Transluminal Angioplasty (PTA). Placement of endovenous stents may be considered as a planned adjunct to suboptimal or failed angioplasty. A suboptimal or failed angioplasty is defined as dilation judged by the physician to be suboptimal or failed due to the presence of unfavorable lesion morphology such as:
- Residual stenosis of more than 30 percent for a vein measured at the narrowest point of the vascular lumen at the site of angioplasty or more than 50 percent reduction of luminal diameter.5(p59)
- A tear that interrupts the integrity of the intima or lumen causing hemorrhage
- Abrupt persistent occlusion or dissection at the site of angioplasty, occlusion elastic recoil or refractory spasm
A stent may be placed as a planned adjunct to angioplasty rather than in response to a suboptimal or failed angioplasty. Primary endovenous stenting is justified for situations where angioplasty alone is not expected to provide a durable result. Endovenous stents may be placed for patients with severely symptomatic venous obstructions due to any of the following:
1. Iliac vein compression syndrome also known as May-Thurner or Cockett syndrome
2. Iliocaval obstruction
3. Iliofemoral obstruction for patients with venous leg ulceration(s) not relieved by conservative therapies and compression. Progression of symptoms may lead to Phlegmasia Cerulea Dolens (PCD), acute inferior vena cava (IVC) thrombosis, and rapid thrombus extension despite anticoagulation as well as anatomically extensive DVT affecting the common femoral and/or iliac vein, or post-thrombotic stenosis with ankle edema of venous origin (i.e., minimum CEAP score 3).
4. Superior or Inferior Vena Caval Thrombosis including Superior Vena Cava syndrome
5. Post-thrombotic syndrome (PTS).
6. As an adjunct to catheter-directed thrombolysis for acute femoroiliocaval deep vein thrombosis when post thrombolysis imaging identifies symptomatic residual stenosis
7. Post radiation venous stenosis
8. Symptomatic post-traumatic venous stenosis including those resulting from central venous catheters or transvenous device (e.g., pacemakers, defibrillators,) pacemaker leads or a history of abdominal and/or pelvic surgery.
9. Salvage of thrombosed or stenotic symptomatic or limited function arteriovenous dialysis access fistulae or grafts with compromised venous outflow, failed angioplasty rapid restenosis, or vessel perforation. This may include treatment of trapping a life threatening thrombus, an aneurysm or pseudoaneurysm that threatens the viability of the AV fistula or graft, or the treatment of a hemodialysis vascular access rupture that cannot be controlled through balloon tamponade.
10. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome.)
11. Transvenous decompression of portosystemic shunts
12. Post-operative stenosis or venous narrowing due to repair of congenital cardiac disease, e.g. sinus venosus Atrial Septal Defect (ASD), discordant atrioventricular connection status post Mustard or Senning repair of Transposition of the Great Arteries (TGA).
13. Pulmonary vein stenosis resulting from congenital malformation, extrinsic compression, sequelae of radiofrequency ablation (RFA), lung transplantation, or status post repair of Total Anomalous Pulmonary Vein Return (TAPVR).
Limitations The following are considered not medically reasonable and necessary:
1. All other uses of endovenous stents not listed as a covered indication in this LCD.
2. The placement of a stent in a vein for which there is no objective-related symptom or limitation of function is considered to be preventive and, therefore, not covered by Medicare.
3. Presence of local or systemic infection is a relative contraindication to venous stenting except under unusual circumstances where the benefit of placing the stent may outweigh the risks. In these circumstances, the documentation should reflect the provider's rationale.
4. Use of stents without U.S. FDA approval.
5. Stenting of popliteal or tibial veins.
6. Venous stenosis less than or equal to 50% of diameter of vein or residual stenosis of less than 30% measured after angioplasty.
7. Venous stenting for idiopathic intracranial hypertension (IIH) is considered investigational and may be considered only in select isolated and unique circumstances upon individual redetermination.
8. A stent(s) that carries an Investigational Device Exemption (IDE) may be covered under Medicare. Medicare coverage of IDE devices is predicated, in part, upon their status with the FDA. Coverage will cease in the event a manufacturer loses (or violates relevant IDE requirements necessitating FDA's withdrawal of) IDE approval. The FDA issues a special identifier number that corresponds to each device or stent(s) granted an IDE.
You can find this rule in the Local Coverage Determination (LCD): Endovenous Stenting (L38231).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.