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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 diagnostic angiography (arteriography) is an invasive procedure for the purpose of evaluating 
the inside of blood vessels and the vasculature to organs of the body and the chambers of the heart. The process 
involves passing a needle or catheter into an artery followed by injection of contrast material and imaging of 
the vascular area or organ in question using digital imaging. With modern noninvasive imaging techniques 
(e.g., duplex ultrasonography, magnetic resonance angiography [MRA], contrast-enhanced computed 
tomographic angiography [CTA]), the need for invasive diagnostic angiography has been significantly reduced. 
Currently, invasive angiography is mainly used to clarify contradictory findings of noninvasive studies or in 
conjunction with therapeutic procedures. You can find this rule in the Local Coverage Determination (LCD) 
Aortography and peripheral angiography L36767. 
 
The rules say percutaneous revascularization may be performed by angioplasty with either an uncoated or drug-
eluting balloon, with placement of a bare metal, covered, or drug-eluting stent, by mechanical atherectomy, or 
by intravascular lithotripsy. The use of paclitaxel-coated balloons and stents for percutaneous revascularization 
has recently been called into question, and defended. 
 
Criteria 
A meta-analysis of 7 studies encompassing 542 patients with chronic limb-threatening ischemia due to 
infrapopliteal arterial lesions randomized to percutaneous transluminal angioplasty alone or angioplasty with 
stent placement showed that although immediate patency was higher in the stent group, there was no difference 
in 6-month patency, complication rates, 12-month amputation, or 12- month mortality rates between groups. A 
systematic review and meta-analysis including 6 randomized controlled studies (1015 patients with 
claudication or critical limb ischemia) that compared bypass surgery to endovascular treatment found no 
differences in mortality, symptom improvement, amputation rate, 4-year patency rate, or need for subsequent 
procedures. Looking only at patients with critical limb-threatening ischemia, bypass surgery resulted in more 
procedural complications, but a higher rate of technical success and 1-year patency. A study of 220 patients 
(mean age 69 years) with long femoropopliteal stenosis or occlusion (TransAtlantic Inter-Society Consensus 
(TASC) class C or D) randomized to surgical bypass or placement of a drug-eluting stent found fewer 
complications and shorter hospital stays in the stented group, with no differences seen in 12-month patency, 
freedom from amputation or revascularization, mortality, or symptom score improvement. 
 
Alternatives 
A specialty society guideline, based upon a systematic review of the published evidence, recommends medical 
management, including supervised or structured exercise programs, smoking cessation, glycemic control, 
antihypertensive therapy, platelet inhibitors, statins, and cilostazol, as first-line therapy for intermittent 
claudication. A systematic review and meta-analysis of 5 randomized controlled trials (345 patients) comparing 
endovascular revascularization and a supervised exercise program in patients with intermittent claudication 
found no significant clinical differences between treatments. The same analysis found 3 randomized trials (432 
patients) that compared endovascular revascularization plus supervised exercise vs supervised exercise alone 
and found no significant differences in clinical outcomes. 
 
Operative Status. 
Patients can be treated on an ambulatory basis if they are undergoing lower extremity percutaneous 
revascularization electively (e.g., for claudication) or the procedure is urgent (e.g., for nonhealing ulcer, 
localized infection) and they are without unstable comorbid illness or a presenting clinical situation that 
requires extended (e.g., more than 24 hours post procedure) monitoring. Hospital admission may be necessary 
for patients undergoing an emergent procedure or an urgent procedure (e.g., for nonhealing ulcer, localized 
infection) who present with an unstable or symptomatic comorbidity (e.g., heart failure, coronary artery disease, COPD), who have need for post-thrombolysis monitoring, or whose clinical situation requires 
extended (e.g., more than 24 hours post procedure) monitoring or treatment (e.g., sepsis, coagulopathy, renal 
failure, bilateral femoral access). Hospitalization A study of 6564 patients (median age 67 years) with 
peripheral arterial disease undergoing lower extremity revascularization (35% surgical bypass, 65% 
endovascular) and randomized to post procedure rivaroxaban plus antiplatelet therapy or placebo plus 
antiplatelet therapy found that the rivaroxaban group had a lower 3-year composite outcome of acute limb 
ischemia, amputation, myocardial infarction, stroke, or cardiovascular mortality (17.3% vs 19.9%), as well as 
fewer unplanned subsequent index limb revascularization procedures (17.8% vs 20.0%); however, the 
International Society on Thrombosis and Haemostasias (ISTH)-defined major bleeding events were higher 
(5.9% vs 4.1%). Readmission risk and reduction: Analysis of a Medicare database of 13,256 inpatients (mean 
age 77 years) who underwent tibioperoneal angioplasty for critical limb ischemia found, after multivariate 
analysis, that independent predictors of 30-day hospital readmission were index operative indication of 
gangrene (rather than rest pain or ulcer) and patient history of chronic renal failure. 
 
Length of Stay 
Database analysis of treatment for isolated femoropopliteal lesions found that 65% of 5894 patients undergoing 
percutaneous transluminal angioplasty, 78% of 3081 patients undergoing atherectomy, and 64% of 6336 
patients undergoing stenting were treated in the outpatient setting. Analysis of procedure data for a large 
commercially insured population shows 77% of lower extremity percutaneous revascularization procedures 
being performed on an outpatient basis. Analysis of procedure data for a Medicare population shows 76% of 
lower extremity percutaneous revascularization procedures being performed on an outpatient basis. Analysis of 
2056 patients undergoing percutaneous vascular intervention for claudication reports 75% of patients were 
discharged within 1 day. Analysis of national hospital discharge data shows 32% of hospitalized patients 
undergoing a principal procedure of percutaneous revascularization of the lower extremity discharged in 1 day. 
You can find these rules in the Milliman Care Guidelines (MCG) Inpatient & Surgical Care > Optimal 
Recovery Guidelines > Cardiovascular Surgery >Percutaneous Revascularization, Lower Extremity (S-1310). 
 
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.