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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 state that 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. 
A. Of a single coronary artery for patients for whom the likely alternative treatment is coronary bypass 
surgery and who exhibit the following characteristics: 
a. Angina refractory to optimal medical management; 
b. Objective evidence of myocardial ischemia; and 
c. Lesions amenable to angioplasty. 
B. 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. 
C. Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial 
approach. 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved 
Category B Investigational Device Exemption (IDE) Clinical Trials 
Effective July 1, 2001, Medicare covers PTA of the carotid artery concurrent with carotid stent placement 
when furnished in accordance with the FDA-approved protocols governing Category B IDE clinical trials. PTA 
of the carotid artery, when provided solely for the purpose of carotid artery dilation concurrent with carotid 
stent placement, is considered to be a reasonable and necessary service when provided in the context of such a 
clinical trial. 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies 
Effective October 12, 2004, Medicare covers PTA of the carotid artery concurrent with the placement of an 
FDA-approved carotid stent and an FDA-approved or -cleared embolic protection device (effective December 
9, 2009) for an FDA-approved indication when furnished in accordance with FDA-approved protocols governing post-approval studies. The Centers for Medicare & Medicaid Services (CMS) determines that 
coverage of PTA of the carotid artery is reasonable and necessary in these circumstances. 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
Effective March 17, 2005, Medicare covers PTA of the carotid artery concurrent with the placement of an 
FDA-approved carotid stent with embolic protection for the following: 
A. Patients who are at high risk for CEA and who also have symptomatic carotid artery stenosis  70%. 
Coverage is limited to procedures performed using 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); 
B. Patients who are at high risk for CEA and have symptomatic carotid artery stenosis between 50% and 
70%, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine 
cost under the clinical trials policy. 
You can find this rule in the Medicare National Coverage Determination (NCD) for Percutaneous Transluminal 
Angioplasty (PTA), Section 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.