Peripheral Interventions Coverage

CMS Coverage of Percutaneous Transluminal Angioplasty (PTA)¹

The information below is excerpted from Medicare's National Coverage Policy for PTA. To link to the official CMS coverage determination access the web at www.cms.gov and select the following links: Medicare, Medicare Coverage – General Information, Coverage Center, NCDs, Percutaneous Transluminal Angioplasty (PTA).

This procedure involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. With the development and use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used technique for dilating lesions of peripheral, renal, and coronary arteries.

• Nationally Covered Indications
• Nationally Noncovered Indications
• Medicare Coverage
• Commercial Coverage

Nationally Covered Indications

The PTA is covered to treat the following indications:

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 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. The 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.

Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) – For specific information regarding carotid stenting coverage see the Carotid Stenting Coverage section of the website.

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 >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.

Nationally Noncovered Indications

All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain noncovered. The safety and efficacy of these procedures are not established.

All other indications for PTA for which CMS has not specifically indicated coverage remain non-covered.

Medicare Coverage

CMS coverage of PTA with stenting

Medicare coverage of peripheral vessel stenting falls under local Medicare coverage. This means that each local Medicare office has determined their coverage policy for the stenting of peripheral vessels, which may follow PTA. Coverage for peripheral vessel stenting may vary by Medicare Contractor. Therefore, for reimbursement purposes, Abbott Vascular recommends that providers verify Medicare coverage of peripheral procedures prior to date of service.

Commercial Coverage

Commercial Coverage of PTA may vary.

For reimbursement purposes, Abbott Vascular recommends that providers verify insurance coverage prior to performing a procedure.

[1] Medicare National Coverage Determination for Percutaneous Transluminal Angioplasty (PTA), Publication Number 100-3, Manual Section Number 20.7, Version 9, Effective Date December 9, 2009.

References:

Centers for Medicare and Medicaid Services at www.cms.gov

ICD-9-CM for Hospitals – Volumes 1,2 & 3; 2010 Professional; 6th edition; edited by Anita C. Hart, RHIA, CCS, CCS-P, Melinda S. Stegman, MBA, CCS, Beth Ford, RHIT, CCS; Ingenix

CPT® is a trademark of the American Medical Association.

Current Procedure Terminology (CPT®) is copyright 2009. American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

American Medical Association. Current Procedural Terminology (CPT®) 2010. Professional Edition. Chicago, IL.

Last updated: July  2010