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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 say that effective March 17, 2005, Medicare covers Percutaneous Transluminal Angioplasty (PTA) 
of the carotid artery concurrent with the placement of an FDA-approved carotid stent with embolic protection 
for the following: 
 
1) Patients who are at high risk for Carotid Endarterectomy (CEA) and who also have symptomatic carotid 
artery stenosis greater than or equal to 70%. Coverage is limited to procedures performed using Food 
and Drug Administration (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);  
2) Patients who are at high risk for CEA and have symptomatic carotid artery stenosis between 50% and 
70%, in accordance with the Category B Investigational Device Exemption (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 );  
3) 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. 
The use of an FDA-approved or cleared embolic protection device is required. If deployment of the embolic 
protection device is not technically possible, and not performed, then the procedure is not covered by Medicare. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determination (NCD) - Percutaneous Transluminal Angioplasty (PTA) (20.7) 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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.