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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 the Centers for Medicare & Medicaid Services (CMS) covers transcatheter aortic valve 
replacement (TAVR) under Coverage with Evidence Development (CED) with the following conditions: 
 
A. 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: 
 
    1. 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. 
 
    2. 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: 
        a. Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic 
stenosis who have: 
           i. independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic 
valve replacement (SAVR), TAVR or medical or palliative therapy; 
            ii. documented and made available to the other heart team members the rationale for their clinical 
judgment. 
        b. Providers from other physician groups as well as advanced patient practitioners, nurses, research 
personnel and administrators. 
 
    3. The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
 
    4 TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to: 
        a. On-site heart valve surgery and interventional cardiology programs, 
       b. Post-procedure intensive care facility with personnel experienced in managing patients who have 
undergone open-heart valve procedures, 
        c. 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. 
 Qualifications to begin a TAVR program for hospitals without TAVR experience: 
 
The hospital program must have the following: 
 
    a. Greater than or equal to 50 open heart surgeries in the previous year prior to TAVR program initiation, 
and; 
    b. Greater than or equal to 20 aortic valve related procedures in the 2 years prior to TAVR program 
initiation, and; 
    c. Greater than or equal to 2 physicians with cardiac surgery privileges, and; 
    d. Greater than or equal to 1 physician with interventional cardiology privileges, and; 
   e. Greater than or equal to 300 percutaneous coronary interventions (PCIs) per year. 
 
Qualifications to begin a TAVR program for heart teams without TAVR experience: 
 
The heart team must include: 
 
    a. Cardiovascular surgeon with: 
        i. Greater than or equal to 100 career open heart surgeries of which greater than or equal to 25 are aortic 
valve related; and, 
    b. Interventional cardiologist with: 
        i. Professional experience of greater than or equal to 100 career structural heart disease procedures; or, 
greater than or equal to 30 left-sided structural procedures per year; and, 
        ii. Device-specific training as required by the manufacturer. 
 
Qualifications for hospital programs with TAVR experience: 
 
The hospital program must maintain the following: 
 
    a. Greater than or equal to 50 AVRs (TAVR or SAVR) per year including greater than or equal to 20 TAVR 
procedures in the prior year ; or, 
    b. Greater than or equal to 100 AVRs (TAVR or SAVR) every 2 years, including greater than or equal to 40 
TAVR procedures in the prior 2 years; and, 
    c. Greater than or equal to 2 physicians with cardiac surgery privileges; and, 
    d. Greater than or equal to 1 physician with interventional cardiology privileges, and 
    e. Greater than or equal to 300 percutaneous coronary interventions (PCIs) per year; and, 
 
    5. The heart team and hospital are participating in a prospective, national, audited registry that: 1) 
consecutively enrolls TAVR patients; 2) accepts all manufactured devices; 3) follows the patient for at least 
one year; and, 4) complies with relevant regulations relating to protecting human research subjects, including 
45 CFR Part 46 and 21 CFR Parts 50 & 56. You can find this information in Medicare's National Coverage 
Determination (NCD): Transcatheter Aortic Valve Replacement (TAVR) (20.32). 
 
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record. If an unforeseen event, such as a patient's 
death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An 
inpatient admission for a surgical procedure listed by Medicare as inpatient only is generally appropriate, 
regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a 
patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be 
based on the clinical judgment of the physician and must be supported by the medical record. You can find this 
rule at 42 CFR Section 412.3. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.