MIR-2007-2AB, February 2007

Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting

Provider Types Affected
Physicians and providers who may wish to submit claims to Medicare carriers, fiscal intermediaries (FI) and Part A/B Medicare Administrative Contractors (A/B MAC) for PTA Stenting

Provider Action Needed
Be aware that The Centers for Medicare & Medicaid Services (CMS) has reviewed the evidence and determined that, effective for discharges on or after November 6, 2006, Medicare will cover PTA with stenting of intracranial arteries for treatment of cerebral artery stenosis ≥50 percent in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols governing Category B IDE clinical trials. Payment for intracranial PTA with stenting is considered reasonable and necessary under §1862(a)(1)(A) of the Social Security Act under these circumstances. All other indications for intracranial PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain noncovered.

Background
This article and related Change Request (CR) 5432 communicate the findings and revised national coverage determination (NCD) resulting from analysis to determine if PTA should be covered by Medicare. In the past, PTA to treat obstructive lesions of the cerebral arteries was noncovered by Medicare because the safety and efficacy of the procedure had not been established. This NCD meant that the procedure was also noncovered for beneficiaries participating in Food and Drug Administration (FDA) approved Investigational Device Exemption (IDE) clinical trials. On February 9, 2006, a request for reconsideration of this NCD initiated a national coverage analysis.

Key Points

• Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis ≥50 percent in patients with intracranial atherosclerotic disease when furnished in accordance with the Food and Drug Administration (FDA)-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determined that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances.
• Providers billing FIs and A/B MACs should note this coverage applies to claims with:
  • A discharge date on or after November 6, 2006;
  • ICD-9-CM procedure codes of 00.62 and 00.65 both being present;
  • ICD-9CM diagnosis code 437.0 present; and
  • The IDE number present on a 0624 revenue code line.
• Non-institutional providers billing Medicare carriers or A/B MACs should note this coverage applies to claims with:
  • CPT code 37799 (Unlisted procedure, Vascular surgery);
  • A QA modifier to denote Category B IDE clinical trial; and
  • The appropriate IDE number.
• All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain non-covered. The safety and efficacy of these procedures are not established.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5432) issued to your Medicare carrier, FI or A/B MAC. That instruction is contained in two transmittals. The first transmittal is available at http://www.cms.hhs.gov/Transmittals/downloads/R1147CP.pdf on the CMS Web site and it contains the revised portions of the Medicare Claims Processing Manual. The second transmittal contains the national coverage determination and it is available at http://www.cms.hhs.gov/Transmittals/downloads/R64NCD.pdf .

If you have questions, please contact your Medicare carrier, FI or A/B MAC, at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Flu Shot Reminder
It's Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get their annual flu shot and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. It’s Not Too Late! Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5432
Pub. 100- 3, Transmittal# R64NCD, CR# 5432
Pub. 100- 4, Transmittal# R1147CP, CR# 5432
Related CR Release Date: January 5, 2007
Effective Date: November 6, 2006
Implementation Date: February 5, 2007

Do you have your NPI?

National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.