ARCHIVED

Medical Policy

Policy Num:       06.001.048
Policy Name:     NON INVASIVE EVALUATION OF EXTRACRANIAL ARTERIES
Policy ID:          [06.001.048] [Ar / L / M+ / P ] [0.00.00]

Last Review: January 13, 2025

Next Review: ARCHIVED

Related Policies:

None

NON INVASIVE EVALUATION OF EXTRACRANIAL ARTERIES

Popultation Reference No.	Populations	Interventions	Comparators	Outcomes
1	Individuals: presenting with an asymptomatic carotid bruit identified on physical examination.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
2	Individuals: with an symptomatic carotid bruit(s)	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
3	Individuals: with known carotid stenosis	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
4	Individuals: who has had a recent stroke (recent is defined as less than six months) to determine the cause of the stroke.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
5	Individuals: with focal cerebral or ocular transient ischemic symptoms.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
6	Individuals: with syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as suggested by medical history.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
7	Individuals: with retinal arterial emboli (Hollenhorst plaques)	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
8	Individuals: with transient monocular blindness (amaurosis fugax)	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
9	Individuals: with signs/symptoms of subclavian steal syndrome.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
10	Individuals: with proven carotid disease on medical management in whom cerebrovascular symptoms become recurrent.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
11	Individuals: presenting with an injury to the carotid artery or blunt neck trauma.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
12	Individuals: with vasculitis involving the extracranial carotid arteries.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
13	Individuals: with a suspected aneurysm of the carotid artery. This is suspected in patients with swelling of the neck particularly if occurring post carotid endarterectomy.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
14	Individuals: with suspected dissection.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
15	Individuals: with pulsatile neck masses.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
16	Individuals: who are post carotid endarterectomy.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
17	Individuals: whose previous duplex scan revealed a greater than 70% diameter reduction to preoperatively validate the degree of carotid stenosis	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life
18	Individuals: scheduled for major cardiovascular surgical procedures when there is evidence of systemic atherosclerosis.	Interventions of interest are: Carotid doppler arteries ultrasound	Comparators of interest are: Clinical diagnosis	Relevant outcomes include: Funtional outcomes Quality of life

Summary

Non-invasive studies of the extracranial arteries consist of the direct and indirect use of ultrasound methods. The direct tests examine the anatomy and the physiology of the carotid artery while the indirect tests evaluate the hemodynamic changes of its distal branches (the orbital and brain circulation).

Ultrasonography by Doppler evaluates the hemodynamic parameters particularly the speed of blood flow and the characteristics of the flow. This modality evaluates the supraorbital arteries, common carotid, external carotid, internal carotid and vertebral arteries of the neck.

There are two types of peripheral arterial studies:

· Physiological studies - these studies are of functional measures that include analysis of Doppler wave with response to the compression, measures of transcutaneous oxygen pressure or plethysmography.

· A duplex scanning is an ultrasonic study where images and structures are shown in two dimensions and in real time. It also includes a spectral analysis with speed of blood flow.

Objective

The evaluation of the extracranial arteries is of utility to evaluate a patient that presents an asymptomatic carotid bruit but that is identified in a physical examination. Also it is of utility in the evaluation of a patient that has suffered a brain hemorrhage recently.

Policy Statements

Non-invasive studies are recognized for payment if the results impact the clinical course of the patient, for example, they are considered unnecessary when the patient requires

other diagnostic tests or treatments regardless of the outcome of the non-invasive studies.

Performing non-invasive extracranial studies (CPT 93880 or 93881) and evaluation Non-invasive limb veins (CPT 93965, 93970 or 93971) in it encounter is not appropriate as a

general practice or accepted protocol and consequently they should not be billed.

Non-invasive physiological studies of extracranial arteries are considered for payment in the evaluation of the following conditions:

• Carotid puffs

• Monitoring of the patient with known carotid stenosis

• Stroke evaluation

• Evaluation of a transient cerebral ischemic attack

• Evaluation of a patient with syncope and symptoms suggestive of arterial disease
vertebrobasilar

• In the preoperative evaluation of a carotid endarterectomy

• In the evaluation of pulsatile masses in the neck

• In the evaluation of amaurosis fugax

• In the evaluation of a patient with vasculitis involving the carotid arteries
extracranial

Policy Guidelines

Non-invasive vascular 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.

Limitations:

Dizziness is not a typical indication unless associated with other localizing signs or symptoms. However, episodic dizziness with symptom characteristics typical of transient ischemic attacks may indicate medical necessity, especially when other more common sources (eg, postural hypotension, arrhythmia or transiently decreased cardiac output as demonstrated by cardiac events monitoring) have been previously excluded.
When reporting syncope as an indication for this service, it is necessary to document that other, more common causes have been ruled out.
When an uninterpretable study results in performing another type of study, only the successful study should be billed.
Non-invasive studies are reasonable and necessary only if the outcome will potentially impact the clinical course of the patient.

Benefit Application

BlueCard/National Account Issues

Not applicable.

Background

Non-invasive extracranial arterial studies will be considered medically reasonable and necessary under the following
circumstances:
• To initially evaluate a patient presenting with an asymptomatic carotid bruit identified on physical examination. However,
repeatedly using this test for a patient with an asymptomatic carotid bruit with no evidence of carotid stenosis is routine
monitoring. As such, it is considered screening and is noncovered.
• To evaluate a symptomatic patient with a carotid bruit(s).
• To monitor a patient with known carotid stenosis. Patients demonstrating a diameter reduction of 30-50% are normally
followed on an annual basis, whereas patients with a diameter reduction of greater than 50% are normally followed every
six months. It is not necessary to monitor patients with a diameter reduction of less than 30%.
• To initially evaluate a patient who has had a recent stroke (recent is defined as less than six months)to determine the cause of the stroke.
• To evaluate a patient with focal cerebral or ocular transient ischemic symptoms (including, but not limited to, localizing symptoms, weakness of one side of the face, slurred speech, weakness of limb, ocular microembolism, arterial occlusions on retinal examination (branch or central), ischemic optic neuropathy, suspected dural or carotid cavernous fistulae). Ocular transient ischemic attacks are defined as retinal or visual field deficits and not temporarily blurred vision.
• To evaluate a patient with syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as suggested by medical history.
• To evaluate a patient with retinal arterial emboli (Hollenhorst plaques)
• To evaluate a patient with transient monocular blindness (amaurosis fugax).
• To evaluate a patient with signs/symptoms of subclavian steal syndrome. The symptoms usually associated with subclavian steal syndrome are a bruit in the supraclavicular fossa, unequal radial pulses, arm claudication following minimal exercise, and a difference of 20mmHg or more between the systolic blood pressures in the arms.
• To evaluate a patient with proven carotid disease on medical management in whom cerebrovascular symptoms become recurrent.
• To evaluate a patient presenting with an injury to the carotid artery or blunt neck trauma.
• To evaluate a patient with vasculitis involving the extracranial carotid arteries.
• To evaluate a patient with a suspected aneurysm of the carotid artery. This is suspected in patients with swelling of the neck particularly if occurring post carotid endarterectomy.
• To evaluate a patient with suspected dissection
To evaluate pulsatile neck masses.
• To monitor patients who are post carotid endarterectomy. These patients are normally followed with duplex ultrasonography on the affected side at 6 weeks, 6 months, 1 year, and annually thereafter.
• To preoperatively validate the degree of carotid stenosis of a patient whose previous duplex scan revealed a greater than 70% diameter reduction. The duplex is only covered when the surgeon questions the validity of the previous study and the repeat test is being performed in lieu of a carotid arteriogram.
Preoperative evaluation of patients scheduled for major cardiovascular surgical procedures when there is evidence of systemic atherosclerosis.
Non-invasive vascular 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.

Limitations:
• Dizziness is not a typical indication unless associated with other localizing signs or symptoms. However, episodic dizziness with symptom characteristics typical of transient ischemic attacks may indicate medical necessity, especially when other more common sources (eg, postural hypotension, arrhythmia or transiently decreased cardiac output as demonstrated by cardiac events monitoring) have been previously excluded.
• When reporting syncope as an indication for this service, it is necessary to document that other, more common causes have been ruled out.
• When an uninterpretable study results in performing another type of study, only the successful study should be billed.
• Non-invasive studies are reasonable and necessary only if the outcome will potentially impact the clinical course of the patient. For example, the studies are unnecessary when the patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of the non-invasive studies. If it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not medically necessary.
• Performance of both non-invasive extracranial arterial studies (CPT codes 93880 or 93882) and non- invasive evaluation of extremity veins (CPT codes 93970 or 93971) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected (American College of Radiology, 2010).
Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available upon request.
Methods Not Acceptable For Reimbursement:

• Pulse delay oculoplethysmography
• Carotid phonoangiography and other forms of bruit analysis are covered services, but are included in the reimbursement for the office visit
• Periorbital photoplethysmography
• Thermography
• Light reflection rheography
• Photoelectric plethysmograph,
• Mechanical oscillometry
• Inductance plethysmography
• Capitance plethysmography

The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered part of the physical examination of the vascular system and is not separately reported (CPT 2010). The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. If an examination is performed with hand- carried equipment, the quality of the exam, printout, and report must be in keeping with accepted national standards. Since, the standard for the above indications is a color-duplex scan, portable equipment must be able to produce combined anatomic and spectral flow measurements

Regulatory Status

Not applicable.

Rationale

Population Reference No. 1 Policy Statement

Individuals presenting with an asymptomatic carotid bruit identified on physical examination. Interventions of interest are carotid doppler arteries ultrasound. Comparators of interest are clinical diagnosis. Relevant outcomes include funtional outcomes and quality of life

Population Reference No. 1 Policy Statement

[ x ] MedicallyNecessary

[ ] Investigational