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National Coverage Determination (NCD)

Percutaneous Transluminal Angioplasty (PTA)

20.7

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Tracking Information

Publication Number
100-3
Manual Section Number
20.7
Manual Section Title
Percutaneous Transluminal Angioplasty (PTA)
Version Number
1
Effective Date of this Version
07/01/2001
Ending Effective Date of this Version
10/12/2004
Implementation Date
07/01/2001
Implementation QR Modifier Date

Description Information

Benefit Category
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

This procedure involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon.
Indications and Limitations of Coverage

A - 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 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 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.
  • Obstructive lesions of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial approach.

B - PTA is not covered to treat obstructive lesions of the carotid artery except in the following circumstance:

  • Effective July 1, 2001, Medicare will cover PTA of the carotid artery concurrent with carotid stent placement when furnished in accordance with the Food and Drug Administration (FDA) approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. PTA of the carotid artery, when provided solely for the purpose of carotid artery dilation concurrent with carotid stent placement, is considered to be a reasonable and necessary service only when provided in the context of such a clinical trial, and therefore is considered a covered service for the purposes of these trials. Performance of PTA in the carotid artery when used to treat obstructive lesions outside of approved protocols governing Category B IDE clinical trials remains a noncovered service.

PTA is not covered to treat obstructive lesions of the vertebral and cerebral arteries. The safety and efficacy of these procedures have not been established.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
137
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R137CIM.pdf
Revision History

05/2001 - Provided coverage of carotid artery only when concurrent with carotid stent placement when furnished in accordance with FDA approved protocols governing Category B IDE clinical trials. Effective and implementation dates 7/1/2001.  (TN 137) (CR 1660)

03/1994 - Expanded coverage to include treatment of atherosclerotic obstructions of vessels in upper extremities.  (Upper extremities does not include head or neck vessels.) Also clarified that PTA covered in treatment of obstructive lesions of arteriovenous dialysis fistulas through either an arterial or venous approach. Effective date 03/17/1994. (TN 68)

07/1991 - Provided coverage in treatment of obstructive lesions of arteriovenous dialysis fistulas and included appropriate ICD-9-CM and HCPCS codes. Effective date 07/29/1991. (TN 49)

11/1985 - Provided for less than restrictive guidelines associated with patient selection criteria. Effective date 11/22/1985. (TN 1)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Percutaneous Transluminal Angioplasty (PTA) 11 10/11/2023 - N/A View
Percutaneous Transluminal Angioplasty (PTA) 10 01/01/2013 - 10/11/2023 View
Percutaneous Transluminal Angioplasty (PTA) 9 12/09/2009 - 01/01/2013 View
Percutaneous Transluminal Angioplasty (PTA) 8 10/14/2008 - 12/09/2009 View
Percutaneous Transluminal Angioplasty (PTA) 7 05/12/2008 - 10/14/2008 View
Percutaneous Transluminal Angioplasty (PTA) 6 02/14/2008 - 05/12/2008 View
Percutaneous Transluminal Angioplasty (PTA) 5 04/30/2007 - 02/14/2008 View
Percutaneous Transluminal Angioplasty (PTA) 4 11/06/2006 - 04/30/2007 View
Percutaneous Transluminal Angioplasty (PTA) 3 03/17/2005 - 11/06/2006 View
Percutaneous Transluminal Angioplasty (PTA) 2 10/12/2004 - 03/17/2005 View
Percutaneous Transluminal Angioplasty (PTA) 1 07/01/2001 - 10/12/2004 You are here
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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