Oxford Health Plans > Medical and Administrative Policies > Duplex Scan of Extracranial Arteries
Title of Medical Policy

Duplex Scan of Extracranial Arteries

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies as well as SecureHorizons and Evercare.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Members plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy #: DIAGNOSTIC 021.6 T0

Coverage Statement:

Policy is applicable to:

    Commercial plans

    AARP MedicareComplete, Evercare Plan DH and SecureHorizons MedicareComplete, including Group Retiree Plans underwritten by Oxford Health Plans (NY/NJ/CT), Inc. (CMS Contract Numbers: H0752, H3107 and H3307)

Conditions of Coverage
Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
Yes - Outpatient, Office
Authorization (Precertification always required for inpatient admission) No
Precertification with MD Review No
Site(s) of Service
(If not listed, MD Review required)
Office, Outpatient

Description of Service/Assessment/Background Information:
Duplex studies of the carotid arteries in the neck are used primarily to (1) determine if a stenosis or ulceration of the carotid arteries is the likely cause of ischemic events in the brain; (2) to diagnose severe stenosis (greater then 60% diameter or greater than 84% cross sectional area) which may require surgery in patients with no symptoms; (3) for follow-up care after surgery, or to determine if condition is progressive or stable; or (4) to image a carotid body tumor or aneurysm.

The accuracy and overall quality of the exam is dependent on many factors, including the specifications of the probe and equipment, the skill and experience of the technician performing the exam, and of the physician supervising the lab and interpreting the study.

Policy and Rationale:
Oxford covers duplex scans of extracranial arteries as stated under Treatment/Application Guidelines.
  1. Oxford will reimburse CPT codes 93880 and 93882 only for conditions listed in the Payment Guidelines section of this policy. Exams for other indications will be denied as not medically necessary.

  2. Effective March 1, 2007, Oxford will reimburse only:

    • Laboratories documented to have obtained accreditation from either the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), or the American College of Radiology (ACR).

      AND

    • Physicians meeting the accreditation requirements outlined by either the ICAVL or ACR, or who are board certified by the American Board of Radiology (ABR).

Treatment/Application Guidelines:
Recommended Guidelines
Indications for duplex scans of extracranial arteries (CPT codes 93880 and 93882) are: Stroke which may have been caused by carotid artery disease (ischemic stroke); or
  • Transient ischemic attack (TIA) involving eyes or brain; or
  • Central nervous system (CNS) symptoms that may be the result of inadequate cerebral blood flow; or
  • Asymptomatic bruits; or
  • Carotid body tumors; or
  • Follow up after carotid endarterectomy or carotid stenting

Payment Guidelines:

Applicable CPT codes:

Applicable CPT Code Description
93880 Duplex scan of extracranial arteries; complete bilateral study
93882 Duplex scan of extracranial arteries; unilateral or limited study

Reimbursable ICD-9 Codes:

ICD-9 Codes Code Description
342.01 Flaccid hemiplegia, affecting dominant side
342.02 Flaccid hemiplegia, affecting nondominant side
342.11 Spastic hemiplegia, affecting dominant side
342.12 Spastic hemiplegia, affecting nondominant side
342.81 Other specified hemiplegia, affecting dominant side
342.82 Other specified hemiplegia, affecting nondominant side
344.01 Quadriplegia and quadriparesis, C1-C4, complete
344.02 Quadriplegia and quadriparesis, C1-C4, incomplete
344.03 Quadriplegia and quadriparesis, C5-C7, complete
344.04 Quadriplegia and quadriparesis, C5-C7, incomplete
344.09 Other quadriplegia and quadriparesis
344.1 Paraplegia
344.2 Diplegia of upper limbs
344.31 Monoplegia of lower limbs, affecting dominant side
344.32 Monoplegia of lower limbs, affecting nondominant side
344.41 Monoplegia of upper limbs, affecting dominant side
344.42 Monoplegia of upper limbs, affecting nondominant side
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.35 Central retinal vein occlusion
362.36 Venous tributary (branch) occlusion
362.37 Venous engorgement
362.84 Retinal ischemia
368.2 Diplopia
368.10 Subjective visual disturbance, unspecified
368.11 Sudden visual loss
368.12 Transient visual loss
368.41 Scotoma involving central area
368.42 Scotoma of blind spot area
368.43 Sector or arcuate defects
368.44 Other localized visual field defect
368.45 Generalized contraction or constriction
368.46 Homonymous bilateral field defects
368.47 Heteronymous bilateral field defects
386.2 Vertigo of central origin
430* Subarachnoid hemorrhage
433.00 Occlusion and stenosis of basilar artery, without mention of cerebral infarction
433.01 Occlusion and stenosis of basilar artery, with cerebral infarction
433.10 Occlusion and stenosis of carotid artery, without mention of cerebral infarction
433.11 Occlusion and stenosis of carotid artery, with cerebral infarction
433.20 Occlusion and stenosis of vertebral artery, without mention of cerebral infarction
433.21 Occlusion and stenosis of vertebral artery, with cerebral infarction
433.30 Occlusion and stenosis of multiple and bilateral arteries, without mention of cerebral infarction
433.31 Occlusion and stenosis of multiple and bilateral arteries, with cerebral infarction
433.80 Occlusion and stenosis of other specified precerebral artery, without mention of cerebral infarction
433.81 Occlusion and stenosis of other specified precerebral artery, with cerebral infarction
433.90 Occlusion and stenosis of unspecified precerebral artery, without mention of cerebral infarction
433.91 Occlusion and stenosis of unspecified precerebral artery, with cerebral infarction
434.00 Cerebral thrombosis without mention of cerebral infarction
434.01 Cerebral thrombosis with cerebral infarction
434.10 Cerebral embolism without mention of cerebral infarction
434.11 Cerebral embolism with cerebral infarction
434.90 Cerebral artery occlusion, unspecified, without mention of cerebral infarction
434.91 Cerebral artery occlusion, unspecified, with cerebral infarction
435.0 Basilar artery syndrome
435.1 Vertebral artery syndrome
435.2 Subclavian steal syndrome
435.3 Vertebrobasilar artery syndrome
435.8 Other specified transient cerebral ischemias
435.9 Unspecified tranient cerebral ischemia
436 Acute, but ill-defined cerebrovascular disease
437.0 Cerebral atherosclerosis
437.1 Other generalized ischemic cerebrovascular disease
437.3 Cerebral aneurysm, nonruptured
437.4 Cerebral arteritis
437.7 Transient global amnesia
442.81 Aneurysm of artery of neck
442.82 Aneurysm of subclavian artery
443.21 Dissection of carotid artery
443.24 Dissection of vertebral artery
780.2 Syncope and collapse
781.2 Abnormality of gait
781.3 Lack of coordination
781.4 Transient paralysis of limb
781.94 Facial weakness
782.0 Disturbance of skin sensation
784.3 Aphasia
784.51 Dysarthria
784.59 Other speech disturbance
785.9 Other symptoms involving cardiovascular system (bruit,)
900.01 Injury to blood vessels of head and neck, common carotid artery
900.02 Injury to blood vessels of head and neck, external carotid artery
900.03 Injury to blood vessels of head and neck, internal carotid artery
900.1 Injury to blood vessels of head and neck, internal jugular vein
901.1 Injury to innominate and subclavian arteries
996.1 Mechanical complication of other vascular device, implant, and graft
996.70 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to unspecified device, implant, and graft
996.71 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to heart valve prosthesis
996.72 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to other cardiac device, implant, and graft
996.73 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to renal dialysis device, implant, and graft
996.74 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to other vascular device, implant, and graft
996.75 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to nervous system device, implant, and graft
996.76 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to genitourinary device, implant, and graft
996.77 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to internal joint prosthesis
996.78 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to other internal orthopedic device, implant and graft
996.79 Other complications of internal (biological) (synthetic) prosthetic device, implant and graft, due to other internal prosthetic device, implant and graft
V12.54 Personal history of transient ischemic attack [TIA], and cerebral infarction without residual deficits
V45.89 Other postprocedural status (use for post carotid stent placement)

References:

  1. "Carotid Screening in the Asymptomatic Patient" Official Statement of the American Institute of Ultrasound in Medicine. Approved June 4, 2003. Retrieved December 5, 2007.

  2. American Society of Echocardiography. Position Statement on Provision of Vascular Ultrasound Services. March 2003.

  3. Empire Medicare Services - New York. "Non-Invasive Vascular Diagnostic Studies." Policy number L3743. Effective December 1, 2007. Retrieved December 5, 2007.

  4. Empire Medicare Services - New Jersey. "Non-Invasive Vascular Diagnostic Studies." Policy number L3580. Effective December 1, 2007. Retrieved December 5, 2007.

  5. American Medical Foundation for Peer Review & Education, www.medicalfoundation.org

  6. American Medical Association. ICD-9CM Code Book.

  7. American Medical Association CPT Expert.

Effective Date: October 1, 2009 through October 31, 2010