SS07 - Examining the Effect of the National Coverage Determination on Carotid Procedures in the State of Michigan

Objectives: In 2023, the Centers for Medicare & Medicaid Services (CMS) released a National Coverage Determination (NCD) for the percutaneous transluminal angioplasty and stenting of the carotid artery. This NCD expanded the coverage for carotid stenting, both Transcarotid Artery Revascularization (TCAR) and Transfemoral Carotid Artery Stenting (TfCAS), to include the patients with >50% symptomatic and >70% asymptomatic carotid stenosis. We sought to explore the effects of this NCD on carotid revascularization (Carotid endarterectomy (CEA), TCAR and TfCAS) rates and outcomes.

Methods: Within a statewide quality collaborative, BMC2, all carotid artery procedures were examined between January 1, 2019 and June 30, 2025. Since hospital volumes in Q2 of 2020 were universally low due to COVID, this quarter was excluded from the analysis. The exposure variable is whether the discharge occurred on or after October 1, 2023, when the NCD went into effect. Using both an interrupted time series analysis, the effect of the NCD was measured across all three procedures in 25 hospitals.

Results: A total of 17,239 patients underwent a carotid artery revascularization during the study period, including 12,591 in the Pre-Policy group and 4,648 in the Post-Policy group. Prior to the NCD, asymptomatic TfCAS was slightly decreasing in volume (slope -0.73) and following the NCD, there was a clear increase in TfCAS procedures (change in slope +3.66, p=0.038). There were non-significant changes in asymptomatic TCAR volumes (change in slope -6.04, p=0.072) and asymptomatic CEA (change in slope -3.03, p=0.629). Post-policy, there was a significant increase in 1-year MACE across all procedures (11% pre-policy, 15.3% post-policy, p< 0.001). This increased MACE remained significant after controlling for patient and hospital factors.

Conclusions: The NCD was associated with a significant increase in the volume of asymptomatic TfCAS procedures when comparing the 5 years prior to the NCD to the 2 years post NCD. This increase in stenting was not observed for TCAR or CEA, both of which experienced non-significant decreases in volume over the same time period. Although there is an increased incidence in MACE among all patients undergoing asymptomatic and symptomatic carotid revascularization during this study, it is unclear if this could be related to the policy change.