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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 state that Medicare covers transcatheter edge-to-edge repair (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: 
1. The procedure is furnished with a mitral valve TEER system that has received FDA premarket 
approval (PMA). 
2. 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: 
a. Cardiac surgeon 
i. With 20 or more mitral valve surgeries per year or 40 or more over two years, 
50% of which are mitral valve repairs; and, 
ii. Who is board eligible or certified in cardiothoracic surgery or similar foreign 
equivalent. 
b. Interventional cardiologist 
i. With professional experience of 50 or more career structural heart disease 
procedures; or 30 or more left-sided structural procedures per year; and, 
ii. With participation in 20 or more career trans-septal interventions including 10 as 
primary or co-primary operator; and, 
iii. Who is board eligible or certified in interventional cardiology or similar foreign 
equivalent. c. Interventional echocardiographer (cardiologist or anesthesiologist) 
i. With professional experience of 10 or more trans-septal guidance procedures and 
30 or more structural heart procedures; and, 
ii. Who is board eligible or certified in transesophageal echocardiography with 
advanced training as required for privileging by the hospital where the TEER is 
performed. 
d. Heart failure cardiologist experienced in treating patients with advanced heart failure 
(only required for functional MR patients); and, 
e. Providers from other physician groups as well as advanced patient practitioners, 
nurses, research personnel, and administrators. 
3. 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: 
a. 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. 
b. 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. 
4. 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. 
5. The facility must have the appropriate infrastructure and experience and the heart team and 
hospital are participating in an approved registry which meets the CED requirements 
 
You can find these rules in 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.