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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 Centers for Medicare & Medicaid Services (CMS) covers TEER of the mitral valve under Coverage with 
Evidence Development (CED) with the following conditions: 
 
A. For the treatment of symptomatic moderate-to-severe or severe functional mitral regurgitation (MR) when 
the patient remains symptomatic despite stable doses of maximally tolerated guideline-directed medical therapy 
(GDMT) plus cardiac resynchronization therapy, if appropriate, or for the treatment of significant symptomatic 
degenerative MR when furnished according to a Food and Drug Administration (FDA)-approved indication 
and when all of the following conditions are met: 
 
    The procedure is furnished with a mitral valve TEER system that has received FDA premarket approval 
(PMA). 
 
    The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, 
multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and 
dedication across medical specialties to offer optimal patient-centered care. The heart team must include the 
following members with experience and training as specified: 
        Cardiac surgeon 
            With = 20 mitral valve surgeries per year or = 40 over two years, 50% of which are mitral valve repairs; 
and, 
            Who is board eligible or certified in cardiothoracic surgery or similar foreign equivalent. 
        Interventional cardiologist 
            With professional experience of = 50 career structural heart disease procedures; or = 30 left-sided 
structural procedures per year; and, 
            With participation in = 20 career trans-septal interventions including 10 as primary or co-primary 
operator; and, 
            Who is board eligible or certified in interventional cardiology or similar foreign equivalent. 
        Interventional echocardiographer (cardiologist or anesthesiologist) 
            With professional experience of = 10 trans-septal guidance procedures and = 30 structural heart 
procedures; and, 
            Who is board eligible or certified in transesophageal echocardiography with advanced training as 
required for privileging by the hospital where the TEER is performed. 
        Heart failure cardiologist experienced in treating patients with advanced heart failure (only required for 
functional MR patients); and,         Providers from other physician groups as well as advanced patient practitioners, nurses, research 
personnel, and administrators. 
 
    Each patient's suitability for surgical mitral valve repair, TEER, or palliative therapy must be evaluated, 
documented, and made available to other heart team members. Additionally, for patients with functional MR, 
the heart team heart failure cardiologist must document that the patient has persistent symptoms despite 
maximally tolerated GDMT and cardiac resynchronization therapy, if appropriate, as described below: 
        For patients with functional MR: the heart team interventional cardiologist and heart team heart failure 
cardiologist independently evaluate the patient using information in the medical record and a face-to-face 
examination. To decrease patient burden, the heart team heart failure cardiologist may meet this requirement 
through a review of the patient's records and images if the patient has an established relationship with a 
cardiologist experienced in treating patients with advanced heart failure. 
        For patients with degenerative MR: the heart team interventional cardiologist and heart team cardiac 
surgeon must independently evaluate the patient using information in the medical record and a face-to-face 
examination. 
 
    An interventional cardiologist or cardiac surgeon from the heart team must perform the mitral valve TEER 
and an interventional echocardiographer from the heart team must perform transesophageal echocardiography 
during the procedure. The interventional echocardiographer may not also furnish anesthesiology during the 
same procedure. The interventional cardiologist and cardiac surgeon may jointly participate in the intra-
operative technical aspects of TEER as appropriate. All physicians who participate in the procedure must have 
device-specific training as required by the manufacturer. 
 
    Mitral valve TEERs must be furnished in a hospital with appropriate infrastructure and experience that 
includes, but is not limited to: 
        On-site heart valve surgery and interventional cardiology programs; 
        Post-procedure intensive care facility with personnel experienced in managing patients who have 
undergone open-heart procedures; 
        Hospital volume requirements below must be met and maintained: 
            = 20 mitral valve surgical procedures for severe MR per year or = 40 over two years, of which at least 
10 (or 20 over two years) must be mitral valve repairs; and, 
            = 2 physicians with cardiac surgery privileges experienced in valvular surgery; and, 
            = 1 physician with interventional cardiology privileges; and, 
            = 300 percutaneous coronary interventions (PCIs) per year. 
 
    The heart team and hospital are participating in a prospective, national, audited registry that: 1) 
comprehensively enrolls TEER patients; 2) accepts all manufactured devices; 3) follows the patient for at least 
one year; and, 4) complies with relevant regulations relating to protecting human research subjects, including 
45 Code of Federal Regulations (CFR) Part 46 and 21 CFR Parts 50 & 56. 
 
    The following outcomes must be tracked by the registry, and the registry must be designed to permit 
identification and analysis of patient, practitioner, and facility level variables that predict each of these 
outcomes: 
        Stroke; 
        All-cause mortality; 
        Repeat TEER or other mitral procedures; 
        Transient Ischemic Attacks (TIAs); 
        Major vascular events; 
        Renal complications; 
        Functional capacity; and 
        Quality of Life (QoL). 
     The registry shall collect all data necessary and have a written executable analysis plan in place to address 
the following questions. Specifically, for the CED question d, this must be addressed through a composite 
metric. For the below CED questions (a-e), the results must be reported publicly as described in CED criterion 
k. 
        When TEER procedures are performed outside a controlled clinical study, how do outcomes and adverse 
events compare to the pivotal clinical studies? 
        How do outcomes and adverse events in subpopulations compare to patients in the pivotal clinical studies? 
        What is the long-term (= 5 year) durability of the device? 
        What are the long-term (= 5 year) outcomes and adverse events? 
        How do the demographics of registry patients compare to the pivotal studies? 
 
    Consistent with section 1142 of the Act, the Agency for Healthcare Research and Quality (AHRQ) supports 
clinical research studies that CMS determines meet the above-listed standards and address the above-listed 
research questions. 
 
You can find this information in the National Coverage Determination (NCD) - Transcatheter Edge-to-Edge 
Repair (TEER) for Mitral Valve Regurgitation (20.33) 
 
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.