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CMS Published NCD 20.7 Percutaneous Transluminal Angioplasty Final Decision Memo

Published on 

Wednesday, October 25, 2023

 | Medicare Coverage 

There are five covered indications in section B of National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) for when PTA is covered.  

In June 2022, the Multispecialty Carotid Alliance (MSCA) submitted a letter to CMS for reconsideration of covered indication B4 (concurrent with carotid stent placement in patients at high risk for carotid endarterectomy (CEA).

On July 11, 2023, CMS published Proposed Decision Memo CAG-00085R8: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting. The scope of this reconsideration was limited to PTA concurrent with CAS including transcarotid artery revascularization (TCAR) procedures.

 

On October 11, 2023, CMS published a Final Decision Memo. CMS summarizes the final changes affecting NCD 20.7 sections B4 and D, which revises Medicare coverage for PTA of the carotid arteries concurrent with stenting by:

  1. Expanding coverage to individuals previously only eligible for coverage in clinical trials.
  2. Expanding coverage to standard surgical risk individuals by removing the limitation of coverage to only high surgical risk individuals.
  3. Removing facility standards and approval requirements.
  4. Adding formal shared decision-making with the individual prior to furnishing CAS; and
  5. Allowing MAC discretion for all other coverage of PTA of the carotid artery concurrent with stenting not otherwise addressed in NCD 20.7.

Shared Decision Making

CMS finalized that prior to carotid artery stenting, practitioners must engage in a formal Shared Decision Making (SDM) interaction with the beneficiary. The shared decision-making must include:  

  • Discussion of all treatment options included carotid endarterectomy (CEA), CAS (which includes transcarotid artery revascularization (TCAR)), and optimal medical therapy (OMT)).
  • Explanation of risks and benefits for each option specific to the beneficiary’s clinical situation.
  • Integration of clinical guidelines (e.g., patient comorbidities and concomitant treatments).
  • Discussion and incorporation of beneficiary’s personal preferences and priorities in choosing a treatment plan.

CMS goes on to note that "While not requiring use of a validated SDM tool in the NCD, we would like to note that we believe CMS is not the appropriate entity to develop a tool or specify how to develop a tool to assist in decision-making for carotid artery disease treatments. We believe this role is best left to clinical societies and other expert bodies."

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.