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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 vascular stents are used to enhance primary patency in arteries and veins, usually at the site 
of stenotic or occlusive lesions. Stents also may be used as an adjunct to technically inadequate Percutaneous 
Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease 
resulting from an occlusive process. This LCD does not address carotid artery stenting, which is subject to 
National Coverage Determination 20.7. 
 
PTA and stenting of vessels is covered only when all of the following conditions are met: 
 The patient has undergone prior thorough medical evaluation and management of symptoms. See below 
under specific categories for guidelines on medical evaluation and management recommendations. 
 Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
 A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed 
PTA (so-called primary stent deployment). Primary stenting is justified for situations where PTA alone 
is not expected to provide a durable result, such as arterial or venous occlusions that carry a high risk 
for distal embolization or rapid recurrence OR occlusive lesions known to be unfavorable for PTA 
alone such as significantly calcified lesions, eccentric lesions, lesions related to external compression 
(e.g., May-Thurner syndrome and malignant compression of the superior vena cava), or ostial renal 
artery stenosis. 
Coverage for non-coronary vascular stents depends on the use of an FDA-approved stent. Several different 
stents are currently used in the medical community. Each device has specific indications described by the FDA 
for approved market uses. Stent placement is covered by Medicare only when an FDA-approved stent is: 
 Used for the FDA-approved indications, OR 
 Used for the above indications supported by the peer medical literature. 
Specific Arterial Indications for PTA and Stenting 
 Brachiocephalic arteries: PTA and stenting may be indicated for treatment of flow-limiting stenosis 
resulting in conditions such as subclavian steal syndrome, upper extremity claudication, ischemic rest 
pain of the arm and hand, non-healing tissue ulceration and focal gangrene. Stenting of the inflow arteries, such as the innominate or subclavian when they are the inflow vessels of an arteriovenous 
fistula for chronic hemodialysis and are significantly stenotic, is often useful. 
 Pulmonary artery: PTA and stenting may be indicated for certain people with congenital pulmonary 
artery stenosis. 
 Renal artery: PTA and stenting may be indicated for renal artery stenosis. The following guidelines 
should be followed when making determination for RAS: 
 
Renal artery stenting is considered appropriate for renal artery dissection; renal artery aneurysm and 
renal artery atherosclerosis greater than 50% in a transplanted kidney.  
 
Renal artery stenting is considered appropriate under the following conditions: 
Flash pulmonary edema or acute coronary syndrome (ACS) with severe hypertension; 
Resistant HTN (Uncontrolled hypertension with failure of maximally tolerated doses of at least three 
antihypertensive agents, one of which is a diuretic, or intolerance to medications); or 
Ischemic nephropathy with chronic kidney disease (CKD) with eGFR < 45 cc/min and global renal 
ischemia (unilateral significant renal artery stenosis with a solitary kidney or bilateral significant renal 
artery stenosis ) without other explanation. 
 
Renal artery stenting may be considered appropriate under the following conditions: 
Unilateral renal artery stenosis with CKD (eGFR < 45cc/min). 
Unilateral renal artery stenosis with prior episodes of congestive heart failure (Stage C). 
Anatomically challenging or high-risk lesion (early bifurcation, small vessel, severe concentric 
calcification, and severe aortic atheroma or mural thrombus). 
 
Renal artery stenting is rarely considered appropriate under the following conditions: 
Unilateral, solitary, or bilateral renal artery stenosis with controlled BP and normal renal function. 
Unilateral, solitary, or bilateral renal artery stenosis with kidney size < 7cm in pole-to-pole length. 
Unilateral, solitary, or bilateral renal artery stenosis with chronic end stage renal disease on 
hemodialysis > 3 months. 
Unilateral, solitary, or bilateral renal artery chronic total occlusion. 
 Lower extremity arteries (aorto-iliac, superficial femoral and infra-popliteal arteries): PTA and 
stent placement in infra-popliteal vessels is not expected to be often indicated and in those cases the 
rationale for stent placement must be thoroughly explained in the record. 
 
PTA and stenting for critical limb ischemia is considered appropriate under the following 
conditions: Limb threatening lower extremity ischemia. 
 
PTA and stenting for claudication may be appropriate under the following conditions: Individuals 
who have failed medical management and home exercise program and continue to have significant 
activity limiting disease, with an anatomically suitable lesion for intervention. Medical management of 
peripheral artery disease (PAD) should include Class I recommendations for antiplatelet therapy, 
statins, home exercise program, smoking cessation including planning, counseling or behavior 
modification and pharmacotherapy if needed. 
 Mesenteric vessels: This includes acute mesenteric ischemia, chronic mesenteric ischemia, mesenteric 
thrombosis, dissection, or any other vascular insufficiency resulting in gastrointestinal symptoms. 
Stenting of the mesenteric vessels is covered only when angioplasty of the vessels would not suffice 
and after the patient has had a thorough medical evaluation and management of symptoms, and for 
whom surgical intervention is the likely alternative. The eligible patients will be required to have 
multiple comorbidities documented making them poor candidates for open surgical procedures. In these 
situations, PTA and stent placement should be considered an alternative to surgery and not an addition 
to medical management. 
 Hemodialysis access graft/fistula: This includes stenosis, restenosis, occlusion and pseudoaneurysm. Specific Venous Stents 
 Superior vena cava and subclavian/innominate veins stents: PTA and stenting are covered for 
superior vena cava syndrome, post-radiation venous stenosis, congenital stenosis, and thrombosis and 
embolism, including acute thrombophlebitis. Stenting of the veins, such as the innominate, subclavian, 
or superior vena cava when they are the outflow vessels of an arteriovenous fistula for chronic 
hemodialysis and are significantly stenotic, is often useful. 
 Inferior vena cava and iliofemoral veins: This includes vena caval and iliofemoral venous occlusions 
and stenosis due to the following: post-radiation venous stenosis, congenital stenosis or webs, extrinsic 
venous compression (May-Thurner syndrome), thrombophlebitis, and symptomatic post-traumatic 
venous stenosis. 
Sequential Procedures 
Vascular obstructions may be caused by thrombosis, embolism, atherosclerosis, or other conditions and may be 
multifocal in a single vascular family or in multiple vascular families. Management options to maintain or re-
establish the patency of a vessel in a particular vascular family include surgery, thrombectomy, embolectomy, 
endarterectomy, thrombolysis, atherectomy, angioplasty, and stent placement. These procedures may be 
performed alone or in sequence. The subsequent procedure(s) is necessary because the initial approach was 
unsuccessful or only partially successful in accomplishing the intended goal (that is, to maintain or re-establish 
the patency of a vessel). An example of this situation is when an atherectomy is followed by an angioplasty and 
the angioplasty followed by the placement of a stent. 
 
Limitations 
1. The placement of a stent in a vessel for which there is no objective-related symptom or limitation of 
function is considered to be preventive, and therefore, not covered by Medicare. 
2. Use of non-coronary vascular stents is covered only after the patient has had a thorough evaluation and 
treatment of symptoms and when PTA of the vessel alone has not or is not expected to sufficiently 
resolve the symptoms making surgery the likely alternative. 
3. A non-coronary intravascular stent(s) that carries an Investigational Device Exemption (IDE) may be 
covered under Medicare. Medicare coverage of IDE devices is predicated, in part, upon their status with 
the FDA. Payment will cease in the event a manufacturer loses (or violates relevant IDE requirements 
necessitating FDAs withdrawal of) IDE approval. The FDA issues a special identifier number that 
corresponds to each device or stent(s) granted an IDE. 
You can find this rule in the Medicare Local Coverage Determination (LCD)- L35998, Non-Coronary Vascular 
Stents. 
 
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.