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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 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. 
 
The rules say 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: 
 
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. 
 
    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. The heart team must include the following members with experience and training as specified: 
        a. Cardiac surgeon 
            i. With greater than or equal to 20 mitral valve surgeries per year or greater than or equal to 40 over two 
years, 50% of which are mitral valve repairs; and, 
            ii. Who is board eligible or certified in cardiothoracic surgery or similar foreign equivalent. 
        b. Interventional cardiologist 
            i. With professional experience of greater than or equal to 50 career structural heart disease procedures; 
or greater than or equal to 30 left-sided structural procedures per year; and, 
            ii. With participation in greater than or equal to 20 career trans-septal interventions including 10 as 
primary or co-primary operator; and, 
            iii. Who is board eligible or certified in interventional cardiology or similar foreign equivalent. 
        c. Interventional echocardiographer (cardiologist or anesthesiologist) 
            i. With professional experience of greater than or equal to 10 trans-septal guidance procedures and 
greater than or equal to 30 structural heart procedures; and, 
            ii. Who is board eligible or certified in transesophageal echocardiography with advanced training as 
required for privileging by the hospital where the TEER is performed. 
        d. Heart failure cardiologist experienced in treating patients with advanced heart failure (only required for 
functional MR patients); and, 
        e. Providers from other physician groups as well as advanced patient practitioners, nurses, research 
personnel, and administrators. 
    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, as described below: 
        a. For patients with functional MR: the heart team interventional cardiologist and heart team heart failure 
cardiologist independently evaluate the patient using information in the medical record and a face-to-face 
examination. To decrease patient burden, the heart team heart failure cardiologist may meet this requirement 
through a review of the patient's records and images if the patient has an established relationship with a 
cardiologist experienced in treating patients with advanced heart failure. 
        b. For patients with degenerative MR: the heart team interventional cardiologist and heart team cardiac 
surgeon must independently evaluate the patient using information in the medical record and a face-to-face 
examination. 
    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 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 procedures; 
        c. Hospital volume requirements below must be met and maintained: 
            i. Greater than or equal to 20 mitral valve surgical procedures for severe MR per year or greater than or 
equal to 40 over two years, of which at least 10 (or 20 over two years) must be mitral valve repairs; and, 
            ii. Greater than or equal to 2 physicians with cardiac surgery privileges experienced in valvular surgery; 
and, 
           iii.  Greater than or equal to 1 physician with interventional cardiology privileges; and, 
            iv. Greater than or equal to 300 percutaneous coronary interventions (PCIs) per year. 
    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.The following outcomes must be 
tracked by the registry, and the registry must be designed to permit identification and analysis of patient, 
practitioner, and facility level variables that predict each of these outcomes: 
        a. Stroke; 
        b. All-cause mortality; 
        c. Repeat TEER or other mitral procedures; 
        d. Transient Ischemic Attacks (TIAs); 
        e. Major vascular events; 
        f. Renal complications; 
        g. Functional capacity; and 
        h. Quality of Life (QoL). 
    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. For the below CED questions (a-e), the results must be reported publicly as described in CED criterion 
k. 
        a. When TEER procedures are performed outside a controlled clinical study, how do outcomes and 
adverse events compare to the pivotal clinical studies? 
        b. How do outcomes and adverse events in subpopulations compare to patients in the pivotal clinical 
studies? 
        c. What is the long-term (= 5 year) durability of the device? 
        d. What are the long-term (= 5 year) outcomes and adverse events? 
        e. How do the demographics of registry patients compare to the pivotal studies? 
 
You can find this information in Medicare's National Coverage Determination (NCD): 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.