What the National Coverage Determination for Carotid Artery Stenting Means for the Treatment of Patients with Carotid Artery Disease.

Background: In October 2023, the Centers for Medicare & Medicaid Services agreed to revisit its national coverage determination (NCD) for carotid artery stenting (CAS). We provide an overview of the arguments presented in favor and against NCD expansion, and discuss the likely ramifications on patient care and outcomes in the future.

Methods: We completed a narrative review of the arguments presented in favor and against NCD expansion.

Results: Arguments presented in favor of the CAS NCD expansion predominantly focused on the outcomes of 4 large multicenter randomized controlled trials published between 2010 and 2021 that reported similar outcomes for composite end points between patients undergoing CAS and carotid endarterectomy. The main arguments against expanding the CAS NCD centered around higher patient stroke risks with CAS, increasing health-care costs, premature decision-making, and the lack of a validated shared decision-making tool that can be readily applied to carotid revascularization.

Conclusions: By expanding the indications for CAS to asymptomatic and standard-risk patients, they will be exposed to excess and unnecessary risks without any evident benefits, potentially leading to widespread adoption of a procedure driven by financial incentives rather than genuine patient benefits.