Radiology Coding Alert

Question: How should we interpret the new Medicare coverage decision for carotid artery stenting (CAS) with embolic protection?


Ohio Subscriber

Answer: Be careful with CAS because the Medicare decision does limit when it will accept CAS claims.The current coverage policy states that Medicare will cover carotid stent placement and angioplasty when it is performed in an approved facility on a high-risk patient. You can view the CMS decision memo on CAS at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=157.
 
The following is a summary of the Medicare coverage criteria for CAS with embolism protection:

1. Patients at high risk for carotid endarterectomy (CEA) and who also have symptomatic carotid artery stenosis > 70 percent. Medicare limits coverage to procedures performed using FDA-approved carotid artery stenting systems and embolic protection devices.
 
2. Patients at high risk for CEA and who have symptomatic carotid artery stenosis between 50 percent and 70 percent, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost under the clinical trials policy (NCD Manual 310.1), or in accordance with the National Coverage Determination on CAS post-approval studies (NCD Manual 20.7).

3. Patients at high risk for CEA and who have asymptomatic carotid artery stenosis > 80 percent, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost under the clinical trials policy (NCD Manual 310.1), or in accordance with the National Coverage Determination on CAS post-approval studies (NCD Manual 20.7).

If the patient's carotid stenosis has been measured only by duplex scan, the physician should measure it by angiography before placing the stent. If the stenosis is less than 70 percent, CMS says the CAS shouldn't proceed.

Helpful: Medlearn Matters released "Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA)," at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3811.pdf.