Appeal type: unknown
Decision: unknown

 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that percutaneous transluminal angioplasty (PTA) services are covered when used for treatment 
of atherosclerotic obstructive lesions, concurrent with carotid stent placement in Food and Drug Administration 
(FDA)-Approved Category B Investigational Device Exemption (IDE) Clinical Trials, concurrent with carotid 
stent placement in FDA-Approved Post Approval Studies, and concurrent with carotid stent placement in 
patients at high risk for Carotid Endarterectomy (CEA). You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-03, Medicare National Coverage 
Determinations (NCD) Manual: Percutaneous Transluminal Angioplasty (PTA) (20.7). 
 
The rules say that vascular stents are used to enhance primary patency in arteries and veins, usually at the site 
of stenotic or occlusive lesions. Stents also may be used as an adjunct to technically inadequate Percutaneous 
Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease 
resulting from an occlusive process. 
PTA and stenting of vessels is covered only when all of the following conditions are met: 
- The patient has undergone prior thorough medical evaluation and management of symptoms. 
- Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
- A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed PTA (so-
called primary stent deployment). Primary stenting is justified for situations where PTA alone is not expected 
to provide a durable result, such as arterial or venous occlusions that carry a high risk for distal embolization or 
rapid recurrence OR occlusive lesions known to be unfavorable for PTA alone such as significantly calcified 
lesions, eccentric lesions, lesions related to external compression, or ostial renal artery stenosis. 
PTA and stent placement in infra-popliteal vessels is not expected to be often indicated and in those cases the 
rationale for stent placement must be thoroughly explained in the record. 
 
PTA and stenting for critical limb ischemia is considered appropriate when there is evidence of limb 
threatening lower extremity ischemia. 
 
PTA and stenting for claudication may be appropriate for individuals who have failed medical management and 
home exercise program and continue to have significant activity limiting disease, with an anatomically suitable 
lesion for intervention. Medical management of peripheral artery disease (PAD) should include Class I 
recommendations for antiplatelet therapy, statins, home exercise program, smoking cessation including 
planning, counseling or behavior modification and pharmacotherapy if needed. 
 
You can find this information in the Local Coverage Determination (LCD): Non-Coronary Vascular Stents 
(L35998). 
 
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.