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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 this procedure involves inserting a balloon catheter into a narrow or occluded blood vessel to 
recanalize and dilate the vessel by inflating the balloon. The objective of percutaneous transluminal angioplasty 
(PTA) is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased 
and embolization is decreased. With the development and use of balloon angioplasty for treatment of 
atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used 
technique for dilating lesions of peripheral, renal, and coronary arteries. 
 
The 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. 
 
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. 
 
Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., 
recurrent stenosis and/or previous radical neck dissection) and would be poor candidates for CEA. Significant 
comorbid conditions include but are not limited to: 
 
    Congestive heart failure (CHF) class III/IV; 
    Left ventricular ejection fraction (LVEF) < 30 %; 
    Unstable angina; 
    Contralateral carotid occlusion; 
    Recent myocardial infarction (MI); 
    Previous CEA with recurrent stenosis; 
    Prior radiation treatment to the neck; and 
    Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting 
trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II. 
 
Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological 
dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (modified 
Rankin scale < 3 with symptoms for 24 hours or more), and transient monocular blindness (amaurosis fugax). 
Patients who have had a disabling stroke (modified Rankin scale = 3) shall be excluded from coverage. 
 
The determination that a patient is at high risk for CEA and the patients symptoms of carotid artery stenosis 
shall be available in the patient medical records prior to performing any procedure. 
 
The degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or carotid artery 
angiography and recorded in the patient's medical records. If the stenosis is measured by ultrasound prior to the 
procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the 
stenosis is determined to be < 70% by angiography, then CAS should not proceed. 
 
In addition, CMS has determined that CAS with embolic protection is reasonable and necessary only if 
performed in facilities that have been determined to be competent in performing the evaluation, procedure and 
follow-up necessary to ensure optimal patient outcomes. Standards to determine competency include specific 
physician training standards, facility support requirements and data collection to evaluate outcomes during a 
required reevaluation. 
 
You can find these rules in the National Coverage Determination (NCD) Percutaneous Transluminal 
Angioplasty (PTA) 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.