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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 state that the percutaneous transluminal angioplasty (PTA) is covered when used under the following 
conditions: 
1. Treatment of Atherosclerotic Obstructive Lesions 
In the lower extremities, i.e., the iliac, femoral, and popliteal arteries, or in the upper extremities, i.e., the 
innominate, subclavian, axillary, and brachial arteries. The upper extremities do not include head or neck 
vessels. 
Of a single coronary artery for patients for whom the likely alternative treatment is coronary bypass surgery 
and who exhibit the following characteristics: 
 Angina refractory to optimal medical management; 
 Objective evidence of myocardial ischemia; and 
 Lesions amenable to angioplasty. 
Of the renal arteries for patients in whom there is an inadequate response to a thorough medical management 
of symptoms and for whom surgery is the likely alternative. PTA for this group of patients is an alternative to 
surgery, not simply an addition to medical management. 
Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial approach. 
 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) Clinical Trials Effective July 1, 2001, Medicare covers PTA of the 
carotid artery concurrent with carotid stent placement when furnished in accordance with the FDA-approved 
protocols governing Category B IDE clinical trials. PTA of the carotid artery, when provided solely for the 
purpose of carotid artery dilation concurrent with carotid stent placement, is considered to be a reasonable and 
necessary service when provided in the context of such a clinical trial. 
 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies Effective October 12, 
2004, Medicare covers PTA of the carotid artery concurrent with the placement of an FDA-approved carotid 
stent and an FDA-approved or -cleared embolic protection device (effective December 9, 2009) for an FDA-
approved indication when furnished in accordance with FDA-approved protocols governing post-approval 
studies. The Centers for Medicare & Medicaid Services (CMS) determines that coverage of PTA of the carotid 
artery is reasonable and necessary in these circumstances.  
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
Effective March 17, 2005, Medicare covers PTA of the carotid artery concurrent with the placement of an 
FDA-approved carotid stent with embolic protection for the following: 
- Patients who are at high risk for CEA and who also have symptomatic carotid artery stenosis = 70%. 
Coverage is limited to procedures performed using FDA-approved carotid artery stenting (CAS) systems and 
FDA-approved or -cleared (effective December 9, 2009) embolic protection devices. If deployment of the 
embolic protection device is not technically possible, and not performed, then the procedure is not covered by 
Medicare (effective December 9, 2009);  
- Patients who are at high risk for CEA and have symptomatic carotid artery stenosis between 50% and 70%, in 
accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost under the 
clinical trials policy (Medicare National Coverage Determination (NCD) Manual 310.1), or in accordance with 
the NCD on (CAS) post-approval studies (Medicare NCD Manual 20.7); 
- Patients who are at high risk for CEA and have asymptomatic carotid artery stenosis greater than or equal to 
80%, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost 
under the clinical trials policy (Medicare NCD Manual 310.1), or in accordance with the NCD on CAS post- 
approval studies (Medicare NCD Manual 20.7). 
 
Coverage is limited to procedures performed using an FDA-approved CAS, stents and FDA-approved or -
cleared embolic protection devices. 
 
5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials 
Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of 
cerebral artery stenosis greater than or equal to 50% in patients with intracranial atherosclerotic disease when 
furnished in accordance with the FDA-approved protocols governing Category B IDE clinical trials. CMS 
determines that coverage of intracranial PTA and stenting is reasonable and necessary under these 
circumstances. 
 
C. Nationally Non-Covered Indications 
All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral 
arteries remain noncovered. 
 
All other indications for PTA without stenting for which CMS has not specifically indicated coverage remain 
noncovered. 
 
D. Other 
Coverage of PTA with stenting not specifically addressed or discussed in this NCD is at local Medicare 
Administrative Contractor discretion. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 20.7. 
 
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.