Vascular studies include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output or imaging when provided. The use of a simple handheld or other Doppler device that does not produce hard copy output, or that does not permit analysis of bi-directional vascular flow, is considered part of the physical examination of the vascular system and is not separately reimbursable. Doppler procedures performed with zero-crossers (e.g., analog [strip chart recorder] analysis) are also included in this examination as well.

Duplex Scan
Implies an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging.

Physiologic Studies
Implies functional measurement procedures including Doppler Ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements, or plethysmography. A complete study includes pressure measurements and an additional physiologic technique (e.g., Doppler waveforms or plethysmography).

Plethysmography
Implies volume measurement procedures including air, impedance, or strain gauge methods.

Noninvasive vascular testing (NIVT) studies are medically necessary only if the outcome will potentially impact the clinical management of the patient. Services are deemed medically necessary when all of the following conditions are met:

1. Significant signs/symptoms of ischemia are present;
2. The information is necessary for appropriate medical and/or surgical management; and
3. The test is not redundant of other diagnostic procedures that must be performed.

In general, noninvasive studies of the arterial system are utilized when invasive correction is contemplated, but not to follow noninvasive medical treatment regimens. The latter may be followed with physical findings, including Ankle/Brachial Indices (ABI), and/or progression or relief of signs and/or symptoms.

Performance of both the physiologic studies and duplex study during the same encounter is not medically necessary, except for the specific situations defined in this policy.

The performance of simultaneous arterial and venous studies during the same encounter should be rare.

The professional component of noninvasive vascular testing procedures performed intraoperatively is reimbursable only if performed by a physician who is not a member of the operating team.

NIVT procedures will not be covered when performed based on internal protocols of the testing facility. The physician treating the patient must specifically order the procedures in writing.

Cerebrovascular Arterial Studies 
Acceptable methods: Real-time duplex scans; Doppler waveform or spectral analysis; Ocular pneumoplethysmography (OPG-Gee), Transcranial Doppler (TCD).

Non-covered methods: Pulse delay oculoplethysmography (OPG-K), carotid bruit analysis, carotid phonoangiography and periorbital photoplethysmography.

Indications

Extracranial Cerebrovascular Studies (procedure codes 93875-93882):

1. Evaluation of patients with hemispheric neurologic symptoms, including stroke, transient ischemic attack, and amaurosis fugax.
   
   
2. Evaluation of patients with a cervical bruit.
   
   
3. Evaluation of pulsatile neck masses.
   
   
4. Evaluation of blunt neck trauma.
   
   
5. Evaluation of postoperative patients following carotid surgery.
   
   
6. Evaluation of suspected subclavian steal syndrome.
   
   
7. Preoperative evaluation in patients scheduled for major cardiovascular surgical procedures.
   
   
8. Intraoperative monitoring of vascular surgery.

Ocular pneumoplethysmography (OPG-GEE [procedure code 93875]) may be allowed in addition to procedure codes 93880-93882 when it is necessary to confirm carotid stenosis greater than 50%, or to evaluate onset of neurologic symptoms in the post-operative period.

Transcranial Doppler Studies (procedure codes 93886-93893):

1. The evaluation of hemodynamic effects of severe stenosis or occlusion of the extracranial arteries greater than or equal to 60% diameter reduction or major basal intracranial artery stenosis greater than or equal to 50% diameter reduction.
   
   
2. Detection and serial evaluation of cerebral vasospasm due to subarachnoid hemorrhage (spontaneous or traumatic).
   
   
3. Evaluation of cerebral arteriovenous malformations when surgical intervention is an option.
   
   
4. Intraoperative and perioperative monitoring of intracranial hemodynamics during carotid endarterectomy.
   
   
5. Evaluation of cerebral embolism.
   
   
6. Evaluation of hemodynamics in suspected brain death.

Limitations 

Extracranial Cerebrovascular Studies (procedure codes 93875-93882):

1. For a patient with stenosis of 20 - 49%, annual follow-up may be necessary.
   
   
2. For a patient with stenosis of 50 - 80%, repeat studies usually no more than every 6 months.
   
   
3. For a patient with stenosis of 81 - 99 %, surgery is commonly performed. If not performed, further surveillance is not usually necessary, unless symptoms are progressive.
   
   
4. After carotid endarterectomy, surveillance testing is usually done at 6 weeks, 6 months, and annually thereafter. Repeat testing may also be covered for recurrent or new neurological events.
   
   
5. Carotid phonoangiography and other forms of bruit analysis are covered services in the reimbursement for an office visit.

Transcranial Doppler Studies (codes 93886–93893):  These studies are not medically necessary for the routine evaluation of cerebrovascular symptoms and signs, such as:

• Dizziness, not associated with localizing symptoms;
• Headaches;
• Brain tumors;
• Familial and degenerative disease of the central nervous system;
• Psychiatric disorders;
• Epilepsy;
• Migraine;
• Intraoperative monitoring during major surgery other than intra or extracranial cerebrovascular surgery;
• Assessment of physiologic and pharmacologic responses of cerebral arteries;
• Clinical instability of patients with intracranial hemorrhage or intracranial vascular surgery;
• Inconclusive study for brain death.

Extremity Arterial Studies
Acceptable methods: Duplex scans; Doppler waveform or spectral analysis; volume, impedance or strain gauge plethysmography; transcutaneous oxygen tension measurement.

Noncovered methods: Thermography; mechanical oscillometry; inductance or capacitance plethysmography; photoelectric plethysmography; light reflectance rheography.

A routine history and physical examination, including ABIs, is usually sufficient to document the presence or absence of ischemic disease. It is not medically necessary to proceed beyond the physical examination for signs such as hair loss, absence of a single pulse, relative coolness of a foot, or skin and nail changes unless other signs and/or symptoms of such severity to possibly require invasive intervention are present.

An ABI is not a separately reimbursable procedure. It should be abnormal (i.e., <0.9 at rest), and must be accompanied by another appropriate indication before proceeding to more sophisticated or complete studies, except in patients with medial calcification, as demonstrated by artificially elevated ankle blood pressures.

In most cases, a multilevel physiologic study, which includes pressure and Doppler waveforms, is sufficient for making management decisions. Duplex scanning is a valuable procedure when patients are candidates for an invasive intervention. Duplex scanning and physiologic studies may be reimbursed during the same encounter when the physiologic studies are abnormal or to evaluate vascular trauma, thromboembolic events, aneurysmal disease, or graft patency.

If a patient has falsely elevated arterial pressures due to medial calcinosis, duplex imaging is usually not reliable and the preferred procedures are toe pressures, Doppler waveforms with pulse volume recordings, or transcutaneous oxygen studies.

Exercise studies (code 93924) are useful to differentiate between vascular and neurogenic claudication in patients with spinal stenosis or spondylosis and to determine if a trial of exercise programs may be a reasonable alternate to surgery. It is not necessary to repeat exercise studies after a trial exercise program in the absence of worsening symptoms, since clinical improvement is the goal.

For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not necessary to do both.

Indications

1. Claudication of such severity that it interferes with the patient’s life style or occupation.
   
   
2. Rest pain of ischemic origin.
   
   
3. Ischemic changes of skin in the affected vascular distribution (e.g., gangrene, pre-gangrene, ischemic ulcers).
   
   
4. Evidence of aneurysms or thromboembolism in the extremities.
   
   
5. Blunt or penetrating trauma of the extremities, including complications of diagnostic and therapeutic procedures.
   

Limitations

In the instance where Duplex scanning of the lower extremity arteries is needed, (e.g., trauma, contraindications to angiography), it is unnecessary to routinely image the iliac arteries and the aorta. The extent of imaging must be based on clinical information, such as presence of pulses or region of trauma.

• Following invasive vascular procedures, when reestablished pulses are lost or become equivocal in the immediate postoperative period, or if the patient develops signs and/or symptoms of ischemia for which repeat intervention is considered.
  
  
• Following lower extremity autogenous vein bypass surgeries, a study is usually performed at 3-month intervals during the first year, at 6-month intervals during the second year, and annually thereafter.
  
  
• A patient who is being followed medically develops new or worsening symptoms and/or signs on physical examination.
  
  
• It is appropriate for follow-up studies post-angioplasty, with or without stent placement may be performed at three months, six months, and one year.  Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e., decreased ABI from previous exam) or symptoms (i.e., recurrence of claudication).

Extremity Arterial Studies are not indicated for:

1. Continuous burning of the feet, especially if associated with other evidence of peripheral neuropathy, and when Ankle/Brachial Indices (ABIs) are normal (i.e., 0.9 or >).
   
   
2. Non-specific leg pain.
   
   
3. Edema associated with leg pain when due to venous disease.
   
   
4. Absence of distal pulses (posterior tibial or dorsal pedis) in the absence of ischemic symptoms.

Extremity arterial duplex scans are not indicated when:

1. The determination has already been made that the patient will proceed to angiography; or,
   
   
2. Prior physiologic studies of the lower extremities have established the diagnosis, unless the duplex is being used to select those patients who will benefit from angiography or to define lesions that may be percutaneously dilated.

Extremity Venous Studies
Acceptable methods: Duplex scans; continuous wave Doppler; volume, impedance or strain gauge plethysmography; transcutaneous oxygen tension measurement.

Noncovered methods: Thermography; mechanical oscillometry; inductance or capacitance plethysmography; pulse delay oculoplethysmography, photoelectric plethysmography; light reflectance rheography.

Indications

Indications for venous examinations are separated into three major categories. Studies are medically necessary only when the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedures, or is at high risk for development of deep venous thrombosis (DVT).

1. DVT commonly develops in hospitalized patients after trauma or prolonged immobility (sitting or bed rest). The signs and/or symptoms of DVT are relatively nonspecific. Due to the associated risk of pulmonary embolism (PE), objective testing is allowed in patients who are candidates for anticoagulation or invasive therapeutic procedures, when one of the following is documented:
   • Clinical signs and/or symptoms of DVT including unexplained edema, tenderness, inflammation and/or erythema;
   • History of DVT;
   • Clinical signs and/or symptoms suggestive of PE including hemoptysis, chest pain, and/or dyspnea;
   • Surveillance of patients at high risk for DVT. Surveillance may be necessary following high-risk surgical procedures such as orthopedic or pelvic surgery, or prolonged inactivity. Repeated surveillance is not necessary when effective antithrombotic measures are used (anticoagulants or alternating pressure boots).
     
     
2. Chronic venous insufficiency may be divided into three categories: primary varicose veins, post-thrombotic (post-phlebitic) syndrome, and recurrent deep vein thrombosis. Prior to treatment, objective tests of venous function are indicated in patients with skin ulceration or extremity pain suspected to be secondary to venous insufficiency, since these tests confirm this diagnosis by documenting venous valvular incompetence.
   
   
3. Venous mapping is not always necessary as a routine pre-operative study but is medically reasonable when the patient’s clinical evaluation indicates one of the following:
   • Previous history of vein stripping or sclerotherapy;
   • Severe varicose veins;
   • History of DVT of thrombophlebitis;
   • Previous partial vein harvest;
   • Preoperative mapping prior to scheduled revascularization procedures;
   • Preparations for creating a dialysis fistula when the patient’s clinical evaluation shows that a vein may not be suitable for a fistula.

Limitations

1. Since DVT usually propagates from the calf proximally, studies of the iliac vessels (codes 93978-93979), in addition to the lower extremity studies, are not routinely needed.
   
   
2. Bilateral limb edema due to congestive heart failure, exogenous obesity and/or arthritis would rarely be an indication except when other high-risk conditions are present.
   
   
3. It is not medically necessary to study asymptomatic primary varicose veins.
   
   
4. Mapping the saphenous veins prior to scheduled revascularization procedures is covered when it is expected that an autologous vein will be used, but only if there is uncertainty regarding the availability of a suitable vein for by-pass.

Reasons for Noncoverage

Services provided for conditions not listed on this policy will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

• The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be on request.
• The patient’s medical record must indicate that the treating physician specifically ordered each procedure.
• The medical necessity for performing both physiologic studies and duplex scanning during the same encounter must be documented in the medical record.
• The medical necessity for performing repeat extremity arterial studies must be documented in the medical record.
• The medical necessity for performing arterial and venous studies during the same encounter must be documented in the medical record.
• The medical necessity for performing repeat extremity venous studies must be documented in the medical record.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The following coding guidelines should be used in conjunction with the Noninvasive Vascular Testing:

• Codes 93875, 93922, 93923, and 93965 are complete bilateral studies. When the service is performed unilaterally, use modifier 52 (reduced services), and indicate "unilateral" in the documentation record for electronic and paper claims.
  
  
• Duplex post-interventional follow-up studies are usually limited in scope and unilateral in nature; therefore, the "unilateral or limited study" codes should typically be used.
  
  
• Modifier 50 (bilateral procedure) is not valid for codes 93875-93971.
  
  
• A quantity of "one" must be used for a study of one anatomic area as described in the code definition.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-03, Sections 20.14, 20.17 and 220.5

Use of these codes does not guarantee reimbursement for radiation therapy. The patient’s medical record must document that the coverage criteria in this policy have been met.

Cerebrovascular Arterial Studies (codes 93875-93882, 93931)

Cerebrovascular Arterial Studies (codes 93886-93893)

Extremity Arterial Studies (codes 93922-93923)

Extremity Arterial Studies (code 93924)

Extremity Arterial Studies (codes 93925, 93926)

Extremity Arterial Studies (codes 93930, 93931)

Extremity Venous Studies (codes 93965-93971)