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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 failed conservative management of cardiovascular disease (CVD) may include the need for 
Percutaneous Transluminal Angioplasty (PTA). Placement of endovenous stents may be considered as a 
planned adjunct to suboptimal or failed angioplasty. 
 
A suboptimal or failed angioplasty is defined as dilation judged by the physician to be suboptimal or failed due 
to the presence of unfavorable lesion morphology such as: 
 Residual stenosis of more than 30 percent for a vein measured at the narrowest point of the vascular 
lumen at the site of angioplasty or more than 50 percent reduction of luminal diameter. 
 A tear that interrupts the integrity of the intima or lumen causing hemorrhage. 
 Abrupt persistent occlusion or dissection at the site of angioplasty, occlusion elastic recoil or refractory 
spasm. 
 
A stent may be placed as a planned adjunct to angioplasty rather than in response to a suboptimal or failed 
angioplasty. 
 
Primary endovenous stenting is justified for situations where angioplasty alone is not expected to provide a 
durable result. 
 
Endovenous stents may be placed for patients with severely symptomatic venous obstructions due to any of the 
following: 
1. Iliac vein compression syndrome also known as May-Thurner or Cockett syndrome. 
2. Iliocaval obstruction. 
3. Iliofemoral obstruction for patients with venous leg ulceration(s) not relieved by conservative therapies 
and compression. Progression of symptoms may lead to Phlegmasia Cerulea Dolens (PCD), acute 
inferior vena cava (IVC) thrombosis, and rapid thrombus extension despite anticoagulation as well as 
anatomically extensive deep vein thrombosis (DVT) affecting the common femoral and/or iliac vein, or 
post-thrombotic stenosis with ankle edema of venous origin (i.e., minimum clinical, etiological, 
anatomical, and pathophysiological (CEAP) score 3). 
4. Superior or Inferior Vena Caval Thrombosis including Superior Vena Cava syndrome. 5. Post-thrombotic syndrome (PTS). 
6. As an adjunct to catheter-directed thrombolysis for acute femoroiliocaval deep vein thrombosis when 
post thrombolysis imaging identifies symptomatic residual stenosis. 
7. Post radiation venous stenosis. 
8. Symptomatic post-traumatic venous stenosis including those resulting from central venous catheters or 
transvenous device (e.g., pacemakers, defibrillators,) pacemaker leads or a history of abdominal and/or 
pelvic surgery. 
9. Salvage of thrombosed or stenotic symptomatic or limited function arteriovenous dialysis access 
fistulae or grafts with compromised venous outflow, failed angioplasty rapid restenosis, or vessel 
perforation. This may include treatment of trapping a life threatening thrombus, an aneurysm or 
pseudoaneurysm that threatens the viability of the arteriovenous (AV) fistula or graft, or the treatment 
of a hemodialysis vascular access rupture that cannot be controlled through balloon tamponade. 
10. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome). 
11. Transvenous decompression of portosystemic shunts. 
12. Post-operative stenosis or venous narrowing due to repair of congenital cardiac disease, e.g. sinus 
venosus Atrial Septal Defect (ASD), discordant atrioventricular connection status post Mustard or 
Senning repair of Transposition of the Great Arteries (TGA). 
13. Pulmonary vein stenosis resulting from congenital malformation, extrinsic compression, sequelae of 
radiofrequency ablation (RFA), lung transplantation, or status post repair of Total Anomalous 
Pulmonary Vein Return (TAPVR). 
Y 
ou can find this information in the Local Coverage Determination (LCD): Endovenous Stenting (L37893). 
 
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.