LCD L34045: Non-Invasive Vascular Studies

Abstract:

Non-invasive vascular studies utilize ultrasonic Doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. The display may be a two dimensional image with spectral analysis and color flow or a plethysmographic recording. For the purposes of this policy, non-invasive vascular studies include duplex scans, physiologic studies and plethysmography.

Definitions:

Duplex scan: An ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectrum analysis and/or color flow velocity mapping or imaging.

Physiologic studies: Functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurement, or plethysmography.

Plethysmography: Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative and postoperative evaluation of peripheral artery disease in the internal medicine or vascular surgery practice. It is also a useful tool for the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patient’s candidacy for foot surgery. (CMS Publication 100-03, Medicare National Coverage Decisions Manual , Chapter 1, Section 20.14)

Transcranial Doppler: Pulsed Doppler ultrasound is used to interrogate the intracranial vasculature of the Circle of Willis. Its value has been established in detecting severe stenosis in the major intracranial arteries, assessing patterns and extent of collateral circulation in patients with known regions of severe stenosis or occlusion and evaluating and following patients with vasoconstriction particularly after subarachnoid hemorrhage.

This local coverage determination specifies CGS policy for non-invasive vascular study testing.

INDICATIONS AND LIMITATIONS:

General Indications:

Non-invasive vascular studies are considered medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially impact the clinical management of the patient. Services are deemed medically necessary when the following conditions are met:

• Significant signs/symptoms of arterial or venous disease are present;

• The information is necessary for appropriate medical and/or surgical management; and/or

• The test is not redundant of other diagnostic procedures that must be performed.

In general, non-invasive studies of the arterial system are utilized when invasive correction is contemplated. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record.

Credentialing and Accreditation Standards

The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience and maintain any applicable documentation. A vascular diagnostic study may be personally performed by a physician or a technologist.

The GAO Report to Congressional Committees entitled Medicare Ultrasound Procedures. Consideration of Payment Reforms and Technician Qualifications Requirements states that “Findings from several peer-reviewed studies, the Medicare Payment Advisory Commission, and ultrasound-related professional organizations support requiring that sonographers either have credentials or operate in facilities that are accredited, where specific quality standards apply. In some localities and practice settings, CMS or its contractors have required that sonographers either be credentialed or work in an accredited facility.” (GAO-07-734)

For areas under CGS Administrators, LLC jurisdiction the requirements will be effective for all providers 30 April 2011:

• All non-invasive vascular diagnostic studies must be performed under at least one of the following settings: (1) performed by a physician who is competent in diagnostic vascular studies or under the general supervision of physicians who have demonstrated minimum entry level competency by being credentialed in vascular technology, or (2) performed by a technician who is certified in vascular technology, or (3) performed in facilities with laboratories accredited in vascular technology.

• Examples of appropriate personnel certification include, but are not limited to the Registered Physician in Vascular Interpretation (RPVI), Registered Vascular Technologist (RVT), the Registered Cardiovascular Technologist (RCVT), Registered Vascular Specialist (RVS), and the American Registry of Radiologic Technologists (ARRT) credentials in vascular sonography. Appropriate laboratory accreditation includes the American College of Radiology (ACR) Vascular Ultrasound Program, and the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

• Additionally, transcutaneous oxygen tension measurements may be performed by individuals possessing the following credentials obtained from the National Board of Diving and Hyperbaric Medicine Technology (NBDHMT): Certified Hyperbaric Technologist (CHT), or Certified Hyperbaric Registered Nurse (CHRN).

Please Note: 42 CFR Section 410.33, Independent Diagnostic Testing Facilities, includes credentialing requirements that supersede those above:

The supervising physician must evidence proficiency in the performance and interpretation of each type of diagnostic procedure performed by the IDTF. The proficiency may be documented by certification in specific medical specialties or subspecialties or by criteria established by the carrier for the service area in which the IDTF is located. See 42 CFR Section 410-33 (2) (b).

Nonphysician personnel: Any nonphysician personnel used by the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. See 42 CFR Section 410-33 (2)(c).

General Limitations:

A referral must be on record for each non-invasive study performed. A referral for one type of study does not qualify as a referral for all tests.

Non-invasive vascular studies are considered medically necessary only if the outcome will potentially impact the clinical course of the patient. For example, if a patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of non-invasive studies, and non-invasive vascular procedures will not provide any unique diagnostic information that would impact patient management, then the non-invasive procedures are not medically necessary. 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.

Non-invasive vascular studies include patient care required to perform the studies, supervision of the studies, and interpretation of study results with hard copy output or imaging. Digital storage of imaging is acceptable.

The use of any Doppler device that produces a record that does not permit analysis of bidirectional vascular flow or that does not provide a hard copy printout is part of the physical exam of the vascular system and is not reported separately. ( CPT Expert , 2004, 4th Edition)

The performance of simultaneous arterial and venous studies during the same encounter should be rare. Documentation should be available to support the medical necessity for both studies.

It is rarely necessary to perform cerebrovascular and upper extremity studies on the same day. Documentation supporting the need for both studies should be available for review.

Medicare does not pay for routine screening tests. ICD-10-CM diagnosis code Z13.9 (Special screening of other conditions, unspecified condition) should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of ICD-10-CM code Z13.9 will result in the denial of claims as non-covered screening services.

I. Cerebrovascular Arterial Studies

Extracranial Arterial Studies (93880 - 93882)

Covered cerebrovascular arterial study testing methods include (real-time) duplex scans; and Doppler ultrasound waveform with spectral analysis.

Non-covered/non-reimbursed methods include testing methods that have not been found to be useful based on authoritative technological assessments or that are included as part of the physical examination.

Indications:

Cerebrovascular arterial studies may be considered medically necessary if one or more of the following signs and symptoms are present:

• Asymptomatic or symptomatic cervical bruits;

• Amaurosis fugax;

• Focal cerebral or ocular transient ischemic attacks (including but not limited to):

• localizing symptoms, e.g., sensory loss; and/or

• weakness of one side of the face; and/or

• slurred speech; and/or

• weakness of a limb;

• Syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as suggested by medical history;

• Recent history of a previous neurologic or cerebrovascular event;

• Before major cardiac and vascular surgery when a bruit is noted or there is a history of previous neurologic or cerebrovascular event;

• After carotid endarterectomy (outside the global period), or follow-up of previously documented stenoses;

• Pulsatile neck mass;

• Evaluation of blunt or penetrating neck trauma;

• Ocular microembolism (optic nerve/retinal arterial-Hollenhorst plaques/ocular);

• Arterial Fibromuscular dysplasia

Limitations: Studies may not be considered medically necessary if performed for the following signs and symptoms:

• Drop attack or syncope are rare indications usually seen with vertebrobasilar or bilateral carotid artery disease.

• 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, e.g., postural hypotension or transiently decreased cardiac output as demonstrated by cardiac event monitoring, have been previously excluded; and/or

• Headaches (including migraines).

Duplex ultrasonography has gained an acceptable role in the diagnosis and management of fibromuscular dysplasia. An international consensus document on the diagnosis and management of fibromuscular dysplasia states the first step to confirm clinical suspicion of renal FMD is non-invasive imaging with CTA as the initial test preferred and MRA if CTA is contraindicated. (Gornik 2019)

A European consensus document on the diagnosis and management of fibromuscular dysplasia recommends noninvasive studies in the following scenarios(Persu 2014):

• Duplex ultrasound should be first-line screening test to detect RAS and confirmed by another imaging technique if positive result or if negative result accompanied by high clinical suspicion.

• MR-angiography or CT-angiography are considered first line tests and should be used to confirm diagnosis of renal artery FMD in the following cases

• Results of DUS are suboptimal

• Degree of suspicion of FMD is high and/or

• FMD diagnosis would have major clinical implications.

The American Heart Association published a statement acknowledging the role noninvasive imaging studies such as duplex ultrasonography, CTA, and MRA, with the gold standard as catheter-based angiography as a diagnostic path for renal FMD. (Olin 2014)

Transcranial Doppler (TCD) Studies (93886 – 93893)

Transcranial Doppler (TCD) studies of the intracranial arteries and transcranial duplex imaging of extracranial arteries are approved methods of testing. The presence, location, and extent of disease can be evaluated by utilizing directional pulsed Doppler to estimate flow velocities and assess intracranial vessel hemodynamics and physiology.

Indications:

TCD studies are allowed for the following:

• Detection and evaluation of the hemodynamic effects of severe stenosis or occlusion of the extracranial (greater than or equal to 60% diameter reduction) and major basal intracranial arteries (greater than or equal to 50% diameter reduction);

• Detection and serial evaluation of cerebral vasospasm complicating subarachnoid hemorrhage;

• Evaluation of intracranial hemodynamic abnormalities in patients with suspected brain death;

• Intraoperative and perioperative monitoring of intracranial flow velocity and hemodynamic patterns during carotid endarterectomy, (although the professional component could only be reimbursed if it is provided during the operative procedure by a physician that is not a member of the operating team);

• Evaluation of cerebral embolization; and/or

• Assessing hemodynamic effects, patterns, and extent of collateral circulation in patients with known regions of severe stenosis or occlusion when necessary to care for the patient; and

• Assessing stroke risk in children aged two to sixteen with homozygous sickle cell disease; and

• As an alternative to an echocardiogram to detect residual right to left shunting after repair/closure of an intracardiac or intrapulmonary shunt.

Multiple cerebrovascular procedures may be allowed during the same encounter given the physician/provider can demonstrate medical necessity as documented in the patient’s medical record. For example, physiologic studies and a duplex scan are allowed on the same date of service given the provider is able to document medical necessity, e.g., greater than or equal to 50% stenosis on duplex scan or significant symptoms as demonstrated by the indications for the study.

Limitations:

TCD studies are not indicated for:

• Evaluation of brain tumors;

• Assessment of familial and degenerative disease of the cerebrum, brainstem, cerebellum, basal ganglia and motor neurons;

• Evaluation of infectious and inflammatory conditions;

• Psychiatric disorders; and/or

• Epilepsy.

Transcranial Doppler (TCD) is considered investigational and not medically necessary for the following indications:

• Assessing patients with migraine;

• Monitoring during cardiopulmonary bypass and other cerebrovascular and cardiovascular interventions, and surgical procedures (except during carotid endarterectomy, as noted above);

• Evaluation of patients with dilated vasculopathies such as fusiform aneurysms;

N/A