DUPLEX SCAN OF EXTRACRANIAL ARTERIES - Oxford Health Plans

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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
Page 1: CLINICAL POLICYDUPLEX SCAN OF EXTRA
Page 4 and 5: 433.81Occlusion and stenosis of oth
Page 6 and 7: G82.51 Quadriplegia, C1-C4 complete
Page 8 and 9: I60.7Nontraumatic subarachnoid hemo
Page 10 and 11: I65.29 Occlusion and stenosis of un
Page 12 and 13: T82.320AT82.321AT82.322AT82.328AT82

DUPLEX SCAN OF EXTRACRANIAL ARTERIES - Oxford Health Plans

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