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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 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.  
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. 
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. Mitral valve TEERs must be furnished in a hospital with appropriate infrastructure and experience  
6. The heart team and hospital are participating in a prospective, national, audited registry that: 1) 
comprehensively enrolls TEER 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 Code of Federal Regulations (CFR) Part 46 and 21 CFR Parts 50 & 56. 7. The registry shall collect all data necessary and have a written executable analysis plan in place to 
address the following questions. Specifically, for the CED question d, this must be addressed through a 
composite metric.  
 
Consistent with section 1142 of the Act, the Agency for Healthcare Research and Quality (AHRQ) supports 
clinical research studies that CMS determines meet the above-listed standards and address the above-listed 
research questions. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-03, Medicare National Coverage Determination for 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.