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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 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: 
 
The procedure is furnished with a mitral valve transcatheter edge-to-edge repair (TEER) system that has 
received FDA premarket approval (PMA). 
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: 
Cardiac surgeon 
With = 20 mitral valve surgeries per year or = 40 over two years, 50% of which are mitral valve repairs; and, 
Who is board eligible or certified in cardiothoracic surgery or similar foreign equivalent. 
Interventional cardiologist 
With professional experience of = 50 career structural heart disease procedures; or = 30 left-sided structural 
procedures per year; and, 
With participation in = 20 career trans-septal interventions including 10 as primary or co-primary operator; 
and, 
Who is board eligible or certified in interventional cardiology or similar foreign equivalent. 
Interventional echocardiographer (cardiologist or anesthesiologist) 
With professional experience of = 10 trans-septal guidance procedures and = 30 structural heart procedures; 
and, 
Who is board eligible or certified in transesophageal echocardiography with advanced training as required for 
privileging by the hospital where the TEER is performed. 
Heart failure cardiologist experienced in treating patients with advanced heart failure (only required for 
functional MR patients); and, 
Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel, and administrators. 
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: 
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. 
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. 
 
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. 
 
You can find this information in the 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.