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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 Percutaneous Transluminal Angioplasty (PTA) is covered when used under the following 
conditions: 
 
  
  1. Treatment of Atherosclerotic Obstructive Lesions 
 
In the lower extremities, i.e., the iliac, femoral, and popliteal arteries, or in the upper extremities, i.e., the 
innominate, subclavian, axillary, and brachial arteries. The upper extremities do not include head or neck 
vessels. 
Of a single coronary artery for patients for whom the likely alternative treatment is coronary bypass surgery 
and who exhibit the following characteristics: 
   Angina refractory to optimal medical management; 
   Objective evidence of myocardial ischemia; and 
   Lesions amenable to angioplasty. 
Of the renal arteries for patients in whom there is an inadequate response to a thorough medical management 
of symptoms and for whom surgery is the likely alternative. PTA for this group of patients is an alternative to 
surgery, not simply an addition to medical management. 
Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial approach. 
 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) Clinical Trials 
 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies 
 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
 
Effective March 17, 2005, Medicare covers PTA of the carotid artery concurrent with the placement of an 
FDA-approved carotid stent with embolic protection for the following: 
 
- Patients who are at high risk for CEA and who also have symptomatic carotid artery stenosis less than or 
equal to 70%.; 
- Patients who are at high risk for CEA and have symptomatic carotid artery stenosis between 50% and 70%, in 
accordance with the Category B IDE clinical trials regulation; 
- Patients who are at high risk for CEA and have asymptomatic carotid artery stenosis greater than or equal to 
80%, in accordance with the Category B IDE clinical trials regulation. 
 
Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., 
recurrent stenosis and/or previous radical neck dissection), and would be poor candidates for CEA. Significant 
comorbid conditions include but are not limited to: 
 
Congestive heart failure (CHF) class III/IV; 
Left ventricular ejection fraction (LVEF) < 30 %; 
Unstable angina; 
Contralateral carotid occlusion; 
Recent myocardial infarction (MI); 
Previous CEA with recurrent stenosis; 
Prior radiation treatment to the neck; and 
Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting 
trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II. 
 
Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological 
dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (modified 
Rankin scale less than 3 with symptoms for 24 hours or more), and transient monocular blindness (amaurosis 
fugax). Patients who have had a disabling stroke (modified Rankin scale greater than or equal to 3) shall be 
excluded from coverage. 
 5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials 
 
Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of 
cerebral artery stenosis greater than or equal to 50% in patients with intracranial atherosclerotic disease when 
furnished in accordance with the FDA-approved protocols governing Category B IDE clinical trials. CMS 
determines that coverage of intracranial PTA and stenting is reasonable and necessary under these 
circumstances. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 20.7. 
 
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.