DUPLEX SCAN OF EXTRACRANIAL ARTERIES - Oxford Health Plans

CLINICAL POLICYDUPLEX SCAN OF EXTRACRANIAL ARTERIESPolicy Number: DIAGNOSTIC 021.9 T0Effective Date: November 1, 2012Table of ContentsCONDITIONS OF COVERAGE...................................COVERAGE RATIONALE………………………………BACKGROUND...........................................................APPLICABLE CODES.................................................REFERENCES............................................................POLICY HISTORY/REVISION INFORMATION..........Policy History Revision InformationPage12221415Related Policies:NoneThe services described in Oxford policies are subject to the terms, conditions and limitations of theMember's contract or certificate. Unless otherwise stated, Oxford policies do not apply to MedicareAdvantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary withoutprior written notice unless otherwise required by Oxford's administrative procedures or applicable state law.The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for thesepolicies.Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to theMember's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if thereare any exclusions or benefit limitations applicable to any of these policies. If there is a difference betweenany policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate ofCoverage will govern.CONDITIONS OF COVERAGEApplicable Lines of Business/ProductsBenefit TypeReferral Required(Does not apply to non-gatekeeper products)Authorization Required(Precertification always required for inpatient admission)Precertification with Medical DirectorReview RequiredApplicable Site(s) of Service(If site of service is not listed, Medical Director review isrequired)This policy applies to Oxford Commercial planmembershipGeneral benefits packageYesNoNoOffice, OutpatientDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC1

Applicable ICD-9 CodesICD-9 Procedure CodeDescription342.01 Flaccid hemiplegia, affecting dominant side342.02 Flaccid hemiplegia, affecting nondominant side342.11 Spastic hemiplegia, affecting dominant side342.12 Spastic hemiplegia, affecting nondominant side342.81 Other specified hemiplegia, affecting dominant side342.82 Other specified hemiplegia, affecting nondominant side344.01 Quadriplegia and quadriparesis, C1-C4, complete344.02 Quadriplegia and quadriparesis, C1-C4, incomplete344.03 Quadriplegia and quadriparesis, C5-C7, complete344.04 Quadriplegia and quadriparesis, C5-C7, incomplete344.09 Other quadriplegia and quadriparesis344.1 Paraplegia344.2 Diplegia of upper limbs344.31 Monoplegia of lower limbs, affecting dominant side344.32 Monoplegia of lower limbs, affecting nondominant side344.41 Monoplegia of upper limbs, affecting dominant side344.42 Monoplegia of upper limbs, affecting nondominant side362.31 Central retinal artery occlusion362.32 Arterial branch occlusion362.33 Partial arterial occlusion362.34 Transient arterial occlusion362.35 Central retinal vein occlusion362.36 Venous tributary (branch) occlusion362.37 Venous engorgement362.84 Retinal ischemia368.2 Diplopia368.10 Subjective visual disturbance, unspecified368.11 Sudden visual loss368.12 Transient visual loss368.41 Scotoma involving central area368.42 Scotoma of blind spot area368.43 Sector or arcuate defects368.44 Other localized visual field defect368.45 Generalized contraction or constriction368.46 Homonymous bilateral field defects368.47 Heteronymous bilateral field defects386.2 Vertigo of central origin430 Subarachnoid hemorrhage433.00Occlusion and stenosis of basilar artery, without mention of cerebralinfarction433.01 Occlusion and stenosis of basilar artery, with cerebral infarction433.10Occlusion and stenosis of carotid artery, without mention of cerebralinfarction433.11 Occlusion and stenosis of carotid artery, with cerebral infarction433.20Occlusion and stenosis of vertebral artery, without mention of cerebralinfarction433.21 Occlusion and stenosis of vertebral artery, with cerebral infarction433.30Occlusion and stenosis of multiple and bilateral arteries, withoutmention of cerebral infarction433.31Occlusion and stenosis of multiple and bilateral arteries, with cerebralinfarction433.80Occlusion and stenosis of other specified precerebral artery, withoutmention of cerebral infarctionDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC3

433.81Occlusion and stenosis of other specified precerebral artery, withcerebral infarction433.90Occlusion and stenosis of unspecified precerebral artery, withoutmention of cerebral infarction433.91Occlusion and stenosis of unspecified precerebral artery, withcerebral infarction434.00 Cerebral thrombosis without mention of cerebral infarction434.01 Cerebral thrombosis with cerebral infarction434.10 Cerebral embolism without mention of cerebral infarction434.11 Cerebral embolism with cerebral infarction434.90Cerebral artery occlusion, unspecified, without mention of cerebralinfarction434.91 Cerebral artery occlusion, unspecified, with cerebral infarction435.0 Basilar artery syndrome435.1 Vertebral artery syndrome435.2 Subclavian steal syndrome435.3 Vertebrobasilar artery syndrome435.8 Other specified transient cerebral ischemias435.9 Unspecified tranient cerebral ischemia436 Acute, but ill-defined cerebrovascular disease437.0 Cerebral atherosclerosis437.1 Other generalized ischemic cerebrovascular disease437.3 Cerebral aneurysm, nonruptured437.4 Cerebral arteritis437.7 Transient global amnesia442.81 Aneurysm of artery of neck442.82 Aneurysm of subclavian artery443.21 Dissection of carotid artery443.24 Dissection of vertebral artery780.2 Syncope and collapse781.2 Abnormality of gait781.3 Lack of coordination781.4 Transient paralysis of limb781.94 Facial weakness782.0 Disturbance of skin sensation784.3 Aphasia784.51 Dysarthria784.59 Other speech disturbance785.9 Other symptoms involving cardiovascular system (bruit,)900.01 Injury to blood vessels of head and neck, common carotid artery900.02 Injury to blood vessels of head and neck, external carotid artery900.03 Injury to blood vessels of head and neck, internal carotid artery900.1 Injury to blood vessels of head and neck, internal jugular vein901.1 Injury to innominate and subclavian arteries996.1 Mechanical complication of other vascular device, implant, and graftOther complications of internal (biological) (synthetic) prosthetic996.70device, implant and graft, due to unspecified device, implant, andgraft996.71Other complications of internal (biological) (synthetic) prostheticdevice, implant and graft, due to heart valve prosthesisOther complications of internal (biological) (synthetic) prosthetic996.72device, implant and graft, due to other cardiac device, implant, andgraftOther complications of internal (biological) (synthetic) prosthetic996.73device, implant and graft, due to renal dialysis device, implant, andgraftDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC4

Other complications of internal (biological) (synthetic) prosthetic996.74device, implant and graft, due to other vascular device, implant, andgraftOther complications of internal (biological) (synthetic) prosthetic996.75device, implant and graft, due to nervous system device, implant, andgraftOther complications of internal (biological) (synthetic) prosthetic996.76device, implant and graft, due to genitourinary device, implant, andgraftOther complications of internal (biological) (synthetic) prosthetic996.77device, implant and graft, due to internal joint prosthesisOther complications of internal (biological) (synthetic) prosthetic996.78device, implant and graft, due to other internal orthopedic device,implant and graftOther complications of internal (biological) (synthetic) prosthetic996.79device, implant and graft, due to other internal prosthetic device,implant and graftPersonal history of transient ischemic attack [TIA], and cerebralV12.54infarction without residual deficitsV45.89 Other postprocedural status (use for post carotid stent placement)ICD-10 Codes (Preview Draft)In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2014 * , asample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has beenprovided below for your reference. This list of codes may not be all inclusive and will be updatedto reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in thispolicy. *The effective date for ICD-10 code set implementation is subject to change.ICD-10 Diagnosis CodeDescription(Effective 10/01/14)G04.1 Tropical spastic paraplegiaG45.0 Vertebro-basilar artery syndromeG45.1 Carotid artery syndrome (hemispheric)G45.2 Multiple and bilateral precerebral artery syndromesG45.3 Amaurosis fugaxG45.4 Transient global amnesiaG45.8 Other transient cerebral ischemic attacks and related syndromesG45.9 Transient cerebral ischemic attack, unspecifiedG46.0 Middle cerebral artery syndromeG46.1 Anterior cerebral artery syndromeG46.2 Posterior cerebral artery syndromeG81.01 Flaccid hemiplegia affecting right dominant sideG81.02 Flaccid hemiplegia affecting left dominant sideG81.03 Flaccid hemiplegia affecting right nondominant sideG81.04 Flaccid hemiplegia affecting left nondominant sideG81.11 Spastic hemiplegia affecting right dominant sideG81.12 Spastic hemiplegia affecting left dominant sideG81.13 Spastic hemiplegia affecting right nondominant sideG81.14 Spastic hemiplegia affecting left nondominant sideG81.91 Hemiplegia, unspecified affecting right dominant sideG81.92 Hemiplegia, unspecified affecting left dominant sideG81.93 Hemiplegia, unspecified affecting right nondominant sideG81.94 Hemiplegia, unspecified affecting left nondominant sideG82.20 Paraplegia, unspecifiedG82.21 Paraplegia, completeG82.22 Paraplegia, incompleteG82.50 Quadriplegia, unspecifiedDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC5

G82.51 Quadriplegia, C1-C4 completeG82.52 Quadriplegia, C1-C4 incompleteG82.53 Quadriplegia, C5-C7 completeG82.54 Quadriplegia, C5-C7 incompleteG83.0 Diplegia of upper limbsG83.11 Monoplegia of lower limb affecting right dominant sideG83.12 Monoplegia of lower limb affecting left dominant sideG83.13 Monoplegia of lower limb affecting right nondominant sideG83.14 Monoplegia of lower limb affecting left nondominant sideG83.21 Monoplegia of upper limb affecting right dominant sideG83.22 Monoplegia of upper limb affecting left dominant sideG83.23 Monoplegia of upper limb affecting right nondominant sideG83.24 Monoplegia of upper limb affecting left nondominant sideH34.00 Transient retinal artery occlusion, unspecified eyeH34.01 Transient retinal artery occlusion, right eyeH34.02 Transient retinal artery occlusion, left eyeH34.03 Transient retinal artery occlusion, bilateralH34.10 Central retinal artery occlusion, unspecified eyeH34.11 Central retinal artery occlusion, right eyeH34.12 Central retinal artery occlusion, left eyeH34.13 Central retinal artery occlusion, bilateralH34.211 Partial retinal artery occlusion, right eyeH34.212 Partial retinal artery occlusion, left eyeH34.213 Partial retinal artery occlusion, bilateralH34.219 Partial retinal artery occlusion, unspecified eyeH34.231 Retinal artery branch occlusion, right eyeH34.232 Retinal artery branch occlusion, left eyeH34.233 Retinal artery branch occlusion, bilateralH34.239 Retinal artery branch occlusion, unspecified eyeH34.811 Central retinal vein occlusion, right eyeH34.812 Central retinal vein occlusion, left eyeH34.813 Central retinal vein occlusion, bilateralH34.819 Central retinal vein occlusion, unspecified eyeH34.821 Venous engorgement, right eyeH34.822 Venous engorgement, left eyeH34.823 Venous engorgement, bilateralH34.829 Venous engorgement, unspecified eyeH34.831 Tributary (branch) retinal vein occlusion, right eyeH34.832 Tributary (branch) retinal vein occlusion, left eyeH34.833 Tributary (branch) retinal vein occlusion, bilateralH34.839 Tributary (branch) retinal vein occlusion, unspecified eyeH35.82 Retinal ischemiaH53.10 Unspecified subjective visual disturbancesH53.11 Day blindnessH53.121 Transient visual loss, right eyeH53.122 Transient visual loss, left eyeH53.123 Transient visual loss, bilateralH53.129 Transient visual loss, unspecified eyeH53.131 Sudden visual loss, right eyeH53.132 Sudden visual loss, left eyeH53.133 Sudden visual loss, bilateralH53.139 Sudden visual loss, unspecified eyeH53.2 DiplopiaH53.411 Scotoma involving central area, right eyeH53.412 Scotoma involving central area, left eyeH53.413 Scotoma involving central area, bilateralDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC6

H53.419 Scotoma involving central area, unspecified eyeH53.421 Scotoma of blind spot area, right eyeH53.422 Scotoma of blind spot area, left eyeH53.423 Scotoma of blind spot area, bilateralH53.429 Scotoma of blind spot area, unspecified eyeH53.431 Sector or arcuate defects, right eyeH53.432 Sector or arcuate defects, left eyeH53.433 Sector or arcuate defects, bilateralH53.439 Sector or arcuate defects, unspecified eyeH53.451 Other localized visual field defect, right eyeH53.452 Other localized visual field defect, left eyeH53.453 Other localized visual field defect, bilateralH53.459 Other localized visual field defect, unspecified eyeH53.461 Homonymous bilateral field defects, right sideH53.462 Homonymous bilateral field defects, left sideH53.469 Homonymous bilateral field defects, unspecified sideH53.47 Heteronymous bilateral field defectsH53.481 Generalized contraction of visual field, right eyeH53.482 Generalized contraction of visual field, left eyeH53.483 Generalized contraction of visual field, bilateralH53.489 Generalized contraction of visual field, unspecified eyeH81.41 Vertigo of central origin, right earH81.42 Vertigo of central origin, left earH81.43 Vertigo of central origin, bilateralH81.49 Vertigo of central origin, unspecified earI60.00Nontraumatic subarachnoid hemorrhage from unspecified carotidsiphon and bifurcationI60.01Nontraumatic subarachnoid hemorrhage from right carotid siphon andbifurcationI60.02Nontraumatic subarachnoid hemorrhage from left carotid siphon andbifurcationI60.10Nontraumatic subarachnoid hemorrhage from unspecified middlecerebral arteryI60.11Nontraumatic subarachnoid hemorrhage from right middle cerebralarteryI60.12Nontraumatic subarachnoid hemorrhage from left middle cerebralarteryI60.20Nontraumatic subarachnoid hemorrhage from unspecified anteriorcommunicating arteryI60.21Nontraumatic subarachnoid hemorrhage from right anteriorcommunicating arteryI60.22Nontraumatic subarachnoid hemorrhage from left anteriorcommunicating arteryI60.30Nontraumatic subarachnoid hemorrhage from unspecified posteriorcommunicating arteryI60.31Nontraumatic subarachnoid hemorrhage from right posteriorcommunicating arteryI60.32Nontraumatic subarachnoid hemorrhage from left posteriorcommunicating arteryI60.4 Nontraumatic subarachnoid hemorrhage from basilar arteryI60.50Nontraumatic subarachnoid hemorrhage from unspecified vertebralarteryI60.51 Nontraumatic subarachnoid hemorrhage from right vertebral arteryI60.52 Nontraumatic subarachnoid hemorrhage from left vertebral arteryI60.6Nontraumatic subarachnoid hemorrhage from other intracranialarteriesDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC7

I60.7Nontraumatic subarachnoid hemorrhage from unspecified intracranialarteryI60.8 Other nontraumatic subarachnoid hemorrhageI60.9 Nontraumatic subarachnoid hemorrhage, unspecifiedI63.00 Cerebral infarction due to thrombosis of unspecified precerebral arteryI63.011 Cerebral infarction due to thrombosis of right vertebral arteryI63.012 Cerebral infarction due to thrombosis of left vertebral arteryI63.019 Cerebral infarction due to thrombosis of unspecified vertebral arteryI63.02 Cerebral infarction due to thrombosis of basilar arteryI63.031 Cerebral infarction due to thrombosis of right carotid arteryI63.032 Cerebral infarction due to thrombosis of left carotid arteryI63.039 Cerebral infarction due to thrombosis of unspecified carotid arteryI63.09 Cerebral infarction due to thrombosis of other precerebral arteryI63.10 Cerebral infarction due to embolism of unspecified precerebral arteryI63.111 Cerebral infarction due to embolism of right vertebral arteryI63.112 Cerebral infarction due to embolism of left vertebral arteryI63.119 Cerebral infarction due to embolism of unspecified vertebral arteryI63.12 Cerebral infarction due to embolism of basilar arteryI63.131 Cerebral infarction due to embolism of right carotid arteryI63.132 Cerebral infarction due to embolism of left carotid arteryI63.139 Cerebral infarction due to embolism of unspecified carotid arteryI63.19 Cerebral infarction due to embolism of other precerebral arteryI63.20Cerebral infarction due to unspecified occlusion or stenosis ofunspecified precerebral arteriesI63.211Cerebral infarction due to unspecified occlusion or stenosis of rightvertebral arteriesI63.212Cerebral infarction due to unspecified occlusion or stenosis of leftvertebral arteriesI63.219Cerebral infarction due to unspecified occlusion or stenosis ofunspecified vertebral arteriesI63.22Cerebral infarction due to unspecified occlusion or stenosis of basilararteriesI63.231Cerebral infarction due to unspecified occlusion or stenosis of rightcarotid arteriesI63.232Cerebral infarction due to unspecified occlusion or stenosis of leftcarotid arteriesI63.239Cerebral infarction due to unspecified occlusion or stenosis ofI63.29unspecified carotid arteriesCerebral infarction due to unspecified occlusion or stenosis of otherprecerebral arteriesI63.30 Cerebral infarction due to thrombosis of unspecified cerebral arteryI63.311 Cerebral infarction due to thrombosis of right middle cerebral arteryI63.312 Cerebral infarction due to thrombosis of left middle cerebral arteryI63.319Cerebral infarction due to thrombosis of unspecified middle cerebralarteryI63.321 Cerebral infarction due to thrombosis of right anterior cerebral arteryI63.322 Cerebral infarction due to thrombosis of left anterior cerebral arteryI63.329Cerebral infarction due to thrombosis of unspecified anterior cerebralarteryI63.331 Cerebral infarction due to thrombosis of right posterior cerebral arteryI63.332 Cerebral infarction due to thrombosis of left posterior cerebral arteryI63.339Cerebral infarction due to thrombosis of unspecified posterior cerebralarteryI63.341 Cerebral infarction due to thrombosis of right cerebellar arteryI63.342 Cerebral infarction due to thrombosis of left cerebellar arteryI63.349 Cerebral infarction due to thrombosis of unspecified cerebellar arteryDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC8

I63.39 Cerebral infarction due to thrombosis of other cerebral arteryI63.40 Cerebral infarction due to embolism of unspecified cerebral arteryI63.411 Cerebral infarction due to embolism of right middle cerebral arteryI63.412 Cerebral infarction due to embolism of left middle cerebral arteryI63.419Cerebral infarction due to embolism of unspecified middle cerebralarteryI63.421 Cerebral infarction due to embolism of right anterior cerebral arteryI63.422 Cerebral infarction due to embolism of left anterior cerebral arteryI63.429Cerebral infarction due to embolism of unspecified anterior cerebralarteryI63.431 Cerebral infarction due to embolism of right posterior cerebral arteryI63.432 Cerebral infarction due to embolism of left posterior cerebral arteryI63.439Cerebral infarction due to embolism of unspecified posterior cerebralarteryI63.441 Cerebral infarction due to embolism of right cerebellar arteryI63.442 Cerebral infarction due to embolism of left cerebellar arteryI63.449 Cerebral infarction due to embolism of unspecified cerebellar arteryI63.49 Cerebral infarction due to embolism of other cerebral arteryI63.50Cerebral infarction due to unspecified occlusion or stenosis ofunspecified cerebral arteryI63.511Cerebral infarction due to unspecified occlusion or stenosis of rightmiddle cerebral arteryI63.512Cerebral infarction due to unspecified occlusion or stenosis of leftmiddle cerebral arteryI63.519Cerebral infarction due to unspecified occlusion or stenosis ofunspecified middle cerebral arteryI63.521Cerebral infarction due to unspecified occlusion or stenosis of rightanterior cerebral arteryI63.522Cerebral infarction due to unspecified occlusion or stenosis of leftanterior cerebral arteryI63.529Cerebral infarction due to unspecified occlusion or stenosis ofunspecified anterior cerebral arteryI63.531Cerebral infarction due to unspecified occlusion or stenosis of rightposterior cerebral arteryI63.532Cerebral infarction due to unspecified occlusion or stenosis of leftposterior cerebral arteryI63.539Cerebral infarction due to unspecified occlusion or stenosis ofunspecified posterior cerebral arteryI63.541Cerebral infarction due to unspecified occlusion or stenosis of rightcerebellar arteryI63.542Cerebral infarction due to unspecified occlusion or stenosis of leftcerebellar arteryI63.549Cerebral infarction due to unspecified occlusion or stenosis ofunspecified cerebellar arteryI63.59Cerebral infarction due to unspecified occlusion or stenosis of othercerebral arteryI63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenicI63.8 Other cerebral infarctionI63.9 Cerebral infarction, unspecifiedI65.01 Occlusion and stenosis of right vertebral arteryI65.02 Occlusion and stenosis of left vertebral arteryI65.03 Occlusion and stenosis of bilateral vertebral arteriesI65.09 Occlusion and stenosis of unspecified vertebral arteryI65.1 Occlusion and stenosis of basilar arteryI65.21 Occlusion and stenosis of right carotid arteryI65.22 Occlusion and stenosis of left carotid arteryI65.23 Occlusion and stenosis of bilateral carotid arteriesDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC9

I65.29 Occlusion and stenosis of unspecified carotid arteryI65.8 Occlusion and stenosis of other precerebral arteriesI65.9 Occlusion and stenosis of unspecified precerebral arteryI66.01 Occlusion and stenosis of right middle cerebral arteryI66.02 Occlusion and stenosis of left middle cerebral arteryI66.03 Occlusion and stenosis of bilateral middle cerebral arteriesI66.09 Occlusion and stenosis of unspecified middle cerebral arteryI66.11 Occlusion and stenosis of right anterior cerebral arteryI66.12 Occlusion and stenosis of left anterior cerebral arteryI66.13 Occlusion and stenosis of bilateral anterior cerebral arteriesI66.19 Occlusion and stenosis of unspecified anterior cerebral arteryI66.21 Occlusion and stenosis of right posterior cerebral arteryI66.22 Occlusion and stenosis of left posterior cerebral arteryI66.23 Occlusion and stenosis of bilateral posterior cerebral arteriesI66.29 Occlusion and stenosis of unspecified posterior cerebral arteryI66.3 Occlusion and stenosis of cerebellar arteriesI66.8 Occlusion and stenosis of other cerebral arteriesI66.9 Occlusion and stenosis of unspecified cerebral arteryI67.1 Cerebral aneurysm, nonrupturedI67.2 Cerebral atherosclerosisI67.7 Cerebral arteritis, not elsewhere classifiedI67.81 Acute cerebrovascular insufficiencyI67.82 Cerebral ischemiaI67.841 Reversible cerebrovascular vasoconstriction syndromeI67.848 Other cerebrovascular vasospasm and vasoconstrictionI67.89 Other cerebrovascular diseaseI68.2 Cerebral arteritis in other diseases classified elsewhereI72.0 Aneurysm of carotid arteryI72.8 Aneurysm of other specified arteriesI77.71 Dissection of carotid arteryI77.74 Dissection of vertebral arteryR09.89Other specified symptoms and signs involving the circulatory andrespiratory systemsR20.0 Anesthesia of skinR20.1 Hypoesthesia of skinR20.2 Paresthesia of skinR20.3 HyperesthesiaR20.8 Other disturbances of skin sensationR20.9 Unspecified disturbances of skin sensationR26.0 Ataxic gaitR26.1 Paralytic gaitR26.81 Unsteadiness on feetR26.89 Other abnormalities of gait and mobilityR26.9 Unspecified abnormalities of gait and mobilityR27.0 Ataxia, unspecifiedR27.8 Other lack of coordinationR27.9 Unspecified lack of coordinationR29.5 Transient paralysisR29.810 Facial weaknessR47.01 AphasiaR47.02 DysphasiaR47.1 Dysarthria and anarthriaR47.81 Slurred speechR47.89 Other speech disturbancesR47.9 Unspecified speech disturbancesR55Syncope and collapseDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC10

S15.001AS15.002AS15.009AS15.011AS15.012AS15.019AS15.021AS15.022AS15.029AS15.091AS15.092AS15.099AS15.301AS15.302AS15.309AS15.311AS15.312AS15.319AS15.321AS15.322AS15.329AS15.391AS15.392AS15.399AS25.101AS25.102AS25.109AS25.111AS25.112AS25.119AS25.121AS25.122AS25.129AS25.191AS25.192AS25.199AT82.310AT82.311AT82.312AT82.318AT82.319AUnspecified injury of right carotid artery, initial encounterUnspecified injury of left carotid artery, initial encounterUnspecified injury of unspecified carotid artery, initial encounterMinor laceration of right carotid artery, initial encounterMinor laceration of left carotid artery, initial encounterMinor laceration of unspecified carotid artery, initial encounterMajor laceration of right carotid artery, initial encounterMajor laceration of left carotid artery, initial encounterMajor laceration of unspecified carotid artery, initial encounterOther specified injury of right carotid artery, initial encounterOther specified injury of left carotid artery, initial encounterOther specified injury of unspecified carotid artery, initial encounterUnspecified injury of right internal jugular vein, initial encounterUnspecified injury of left internal jugular vein, initial encounterUnspecified injury of unspecified internal jugular vein, initial encounterMinor laceration of right internal jugular vein, initial encounterMinor laceration of left internal jugular vein, initial encounterMinor laceration of unspecified internal jugular vein, initial encounterMajor laceration of right internal jugular vein, initial encounterMajor laceration of left internal jugular vein, initial encounterMajor laceration of unspecified internal jugular vein, initial encounterOther specified injury of right internal jugular vein, initial encounterOther specified injury of left internal jugular vein, initial encounterOther specified injury of unspecified internal jugular vein, initialencounterUnspecified injury of right innominate or subclavian artery, initialencounterUnspecified injury of left innominate or subclavian artery, initialencounterUnspecified injury of unspecified innominate or subclavian artery,initial encounterMinor laceration of right innominate or subclavian artery, initialencounterMinor laceration of left innominate or subclavian artery, initialencounterMinor laceration of unspecified innominate or subclavian artery, initialencounterMajor laceration of right innominate or subclavian artery, initialencounterMajor laceration of left innominate or subclavian artery, initialencounterMajor laceration of unspecified innominate or subclavian artery, initialencounterOther specified injury of right innominate or subclavian artery, initialencounterOther specified injury of left innominate or subclavian artery, initialencounterOther specified injury of unspecified innominate or subclavian artery,initial encounterBreakdown (mechanical) of aortic (bifurcation) graft (replacement),initial encounterBreakdown (mechanical) of carotid arterial graft (bypass), initialencounterBreakdown (mechanical) of femoral arterial graft (bypass), initialencounterBreakdown (mechanical) of other vascular grafts, initial encounterBreakdown (mechanical) of unspecified vascular grafts, initial11Duplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC

T82.320AT82.321AT82.322AT82.328AT82.329AT82.330AT82.331AT82.332AT82.338AT82.339AT82.390AT82.391AT82.392AT82.398AT82.399AT82.41XAT82.42XAT82.43XAT82.49XAT82.510AT82.511AT82.513AT82.514AT82.515AT82.518AT82.520AT82.521AT82.523AT82.524AT82.525AT82.528AT82.529AT82.530AT82.531AT82.533AT82.534AT82.535AT82.538AT82.590AT82.591AencounterDisplacement of aortic (bifurcation) graft (replacement), initialencounterDisplacement of carotid arterial graft (bypass), initial encounterDisplacement of femoral arterial graft (bypass), initial encounterDisplacement of other vascular grafts, initial encounterDisplacement of unspecified vascular grafts, initial encounterLeakage of aortic (bifurcation) graft (replacement), initial encounterLeakage of carotid arterial graft (bypass), initial encounterLeakage of femoral arterial graft (bypass), initial encounterLeakage of other vascular grafts, initial encounterLeakage of unspecified vascular graft, initial encounterOther mechanical complication of aortic (bifurcation) graft(replacement), initial encounterOther mechanical complication of carotid arterial graft (bypass), initialencounterOther mechanical complication of femoral arterial graft (bypass), initialencounterOther mechanical complication of other vascular grafts, initialencounterOther mechanical complication of unspecified vascular grafts, initialencounterBreakdown (mechanical) of vascular dialysis catheter, initial encounterDisplacement of vascular dialysis catheter, initial encounterLeakage of vascular dialysis catheter, initial encounterOther complication of vascular dialysis catheter, initial encounterBreakdown (mechanical) of surgically created arteriovenous fistula,initial encounterBreakdown (mechanical) of surgically created arteriovenous shunt,initial encounterBreakdown (mechanical) of balloon (counterpulsation) device, initialencounterBreakdown (mechanical) of infusion catheter, initial encounterBreakdown (mechanical) of umbrella device, initial encounterBreakdown (mechanical) of other cardiac and vascular devices andimplants, initial encounterDisplacement of surgically created arteriovenous fistula, initialencounterDisplacement of surgically created arteriovenous shunt, initialencounterDisplacement of balloon (counterpulsation) device, initial encounterDisplacement of infusion catheter, initial encounterDisplacement of umbrella device, initial encounterDisplacement of other cardiac and vascular devices and implants,initial encounterDisplacement of unspecified cardiac and vascular devices andimplants, initial encounterLeakage of surgically created arteriovenous fistula, initial encounterLeakage of surgically created arteriovenous shunt, initial encounterLeakage of balloon (counterpulsation) device, initial encounterLeakage of infusion catheter, initial encounterLeakage of umbrella device, initial encounterLeakage of other cardiac and vascular devices and implants, initialencounterOther mechanical complication of surgically created arteriovenousfistula, initial encounterOther mechanical complication of surgically created arteriovenous12Duplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC

T82.593AT82.594AT82.595AT82.598AT82.817AT82.818AT82.827AT82.828AT82.837AT82.838AT82.847AT82.848AT82.857AT82.858AT82.867AT82.868AT82.897AT82.898AT82.9XXAT83.81XAT83.82XAT83.83XAT83.84XAT83.85XAT83.86XAT83.89XAT83.9XXAT84.81XAT84.82XAshunt, initial encounterOther mechanical complication of balloon (counterpulsation) device,initial encounterOther mechanical complication of infusion catheter, initial encounterOther mechanical complication of umbrella device, initial encounterOther mechanical complication of other cardiac and vascular devicesand implants, initial encounterEmbolism of cardiac prosthetic devices, implants and grafts, initialencounterEmbolism of vascular prosthetic devices, implants and grafts, initialencounterFibrosis of cardiac prosthetic devices, implants and grafts, initialencounterFibrosis of vascular prosthetic devices, implants and grafts, initialencounterHemorrhage of cardiac prosthetic devices, implants and grafts, initialencounterHemorrhage of vascular prosthetic devices, implants and grafts, initialencounterPain from cardiac prosthetic devices, implants and grafts, initialencounterPain from vascular prosthetic devices, implants and grafts, initialencounterStenosis of cardiac prosthetic devices, implants and grafts, initialencounterStenosis of vascular prosthetic devices, implants and grafts, initialencounterThrombosis of cardiac prosthetic devices, implants and grafts, initialencounterThrombosis of vascular prosthetic devices, implants and grafts, initialencounterOther specified complication of cardiac prosthetic devices, implantsand grafts, initial encounterOther specified complication of vascular prosthetic devices, implantsand grafts, initial encounterUnspecified complication of cardiac and vascular prosthetic device,implant and graft, initial encounterEmbolism of genitourinary prosthetic devices, implants and grafts,initial encounterFibrosis of genitourinary prosthetic devices, implants and grafts, initialencounterHemorrhage of genitourinary prosthetic devices, implants and grafts,initial encounterPain from genitourinary prosthetic devices, implants and grafts, initialencounterStenosis of genitourinary prosthetic devices, implants and grafts, initialencounterThrombosis of genitourinary prosthetic devices, implants and grafts,initial encounterOther specified complication of genitourinary prosthetic devices,implants and grafts, initial encounterUnspecified complication of genitourinary prosthetic device, implantand graft, initial encounterEmbolism due to internal orthopedic prosthetic devices, implants andgrafts, initial encounterFibrosis due to internal orthopedic prosthetic devices, implants andgrafts, initial encounterDuplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC13

T84.83XAHemorrhage due to internal orthopedic prosthetic devices, implantsand grafts, initial encounterT84.84XAPain due to internal orthopedic prosthetic devices, implants and grafts,initial encounterT84.85XAStenosis due to internal orthopedic prosthetic devices, implants andgrafts, initial encounterT84.86XAThrombosis due to internal orthopedic prosthetic devices, implants andgrafts, initial encounterT84.89XAOther specified complication of internal orthopedic prosthetic devices,implants and grafts, initial encounterT84.9XXAUnspecified complication of internal orthopedic prosthetic device,implant and graft, initial encounterT85.81XAEmbolism due to internal prosthetic devices, implants and grafts, notelsewhere classified, initial encounterT85.82XAFibrosis due to internal prosthetic devices, implants and grafts, notelsewhere classified, initial encounterT85.83XAHemorrhage due to internal prosthetic devices, implants and grafts,not elsewhere classified, initial encounterT85.84XAPain due to internal prosthetic devices, implants and grafts, notelsewhere classified, initial encounterT85.85XAStenosis due to internal prosthetic devices, implants and grafts, notelsewhere classified, initial encounterT85.86XAThrombosis due to internal prosthetic devices, implants and grafts, notelsewhere classified, initial encounterT85.89XAOther specified complication of internal prosthetic devices, implantsand grafts, not elsewhere classified, initial encounterT85.9XXAUnspecified complication of internal prosthetic device, implant andgraft, initial encounterT86.848 Other complications of corneal transplantT86.849 Unspecified complication of corneal transplantZ86.73Personal history of transient ischemic attack (TIA), and cerebralinfarction without residual deficitsZ97.8 Presence of other specified devicesZ98.3 Post therapeutic collapse of lung statusZ98.62 Peripheral vascular angioplasty statusZ98.89 Other specified postprocedural statesREFERENCES1. American College of Radiology (ACR). Ultrasound Accreditation Program [website].Accessed October 2010. Available at http://www.acr.org.2. American Institute of Ultrasound in Medicine (AIUM). Practice Guideline for the Performanceof an Ultrasound Examination of the Extracranial Cerebrovascular System. October 2007.3. American Institute of Ultrasound in Medicine (AIUM). Official Statement: Carotid Screening inthe Asymptomatic Patient. April 2009.4. Brown OW, et al. Reliability of extracranial carotid artery duplex ultrasound scanning: value ofvascular laboratory accreditation. J Vasc Surg. 2004 Feb;39(2):366-71.5. Intersocietal Commission for the Accreditation of Vascular Laboratories. ICAVL Standards forAccreditation in Noninvasive Vascular Testing. April 2010.Duplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC14

POLICY HISTORY/REVISION INFORMATIONDate11/01/2012Action/DescriptionRoutine review; reorganized policy content (no change tolanguage/guidelines)Archived previous policy version DIAGNOSTIC 021.8 T0Duplex Scan of Extracranial Arteries: Clinical Policy (Effective 11/01/2012)©1996-2012, Oxford Health Plans, LLC15