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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 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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that TAVR is covered for the treatment of symptomatic aortic valve stenosis 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 complete aortic valve and implantation system that has received FDA 
premarket approval (PMA) for that system's FDA approved indication. 
     
The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-
disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication 
across medical specialties to offer optimal patient-centered care. The heart team includes the following: 
         
Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who 
have: 
             
independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic valve 
replacement (SAVR), TAVR or medical or palliative therapy;            
documented and made available to the other heart team members the rationale for their clinical judgment. 
         
Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and 
administrators. 
     The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
     
TAVR must be furnished in a hospital with the appropriate infrastructure 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 valve procedures, 
         
Appropriate volume requirements per the applicable qualifications below: 
 
There are two sets of qualifications; the first set outlined below is for hospital programs and heart teams 
without previous TAVR experience and the second set is for those with TAVR experience. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determination Manual, Transcatheter Aortic Valve 
Replacement (TAVR) (20.32). 
 
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.