CMS Duplex Scanning Form

Summary Of Evidence

N/A

Analysis of Evidence

N/A

Covered Indications

Arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs:

Coverage may be provided for duplex scanning of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs when performed for the following indications:

• To evaluate patients presenting with signs or symptoms such as epigastric or periumbilical postprandial pains that last for 1-3 hours and/or with associated weight loss resulting from decreased oral intake which may indicate chronic intestinal ischemia.
• To evaluate patients presenting with an acute onset of crampy or steady epigastric and periumbilical abdominal pain combined with minimal or no findings on abdominal examination and a high leukocyte count to rule out acute intestinal ischemia.
• To evaluate a patient who has sustained trauma to the abdominal, pelvic and/or retroperitoneal area resulting in a possible injury to the arterial inflow and/or venous outflow of the abdominal, pelvic and/or retroperitoneal organs.
• To evaluate a suspicion of an aneurysm of the renal artery or other visceral artery based on a patient’s signs and symptoms of abdominal pain or noted as an incidental finding on another radiological examination.
• To evaluate a hypertensive patient who has failed first line antihypertensive drug therapy in order to rule out renovascular disease such as renal artery stenosis, renal arteriovenous fistula, or renal aneurysm as a cause for the uncontrolled hypertension.
• To evaluate a patient with signs and symptoms of portal hypertension. These may include abdominal discomfort and distention, abdominal collaterals (caput medusae), abdominal bruit, ascites, encephalopathy, esophageal varices, splenomegaly, etc. 
• To evaluate patients suspected of an embolism, thrombosis, hemorrhage or infarction of the portal vein, renal vein and/or renal artery. These patients may present with many different symptoms such as abdominal discomfort, hematuria, cardiac failure, diastolic hypertension, jaundice, fatigue, weakness, malaise, etc.
• To evaluate patients with pain or swelling of scrotal contents which may be as a result of suspected obstruction in arterial inflow or venous outflow to the testicles or related structures. The use of duplex scanning of scrotal contents should only be performed after conventional diagnostic test, such as ultrasound, have proven to be “non-definitive”;
• To evaluate patients for complications of transplanted organ: kidney, liver or pancreas.
• To evaluate patients diagnosed with hypertensive and normotensive renovascular disease with impaired renal function

Aorta, inferior vena cava, iliac vasculature, or bypass grafts:

Coverage may be provided for duplex scanning of aorta, inferior vena cava, iliac vasculature, or bypass grafts when performed for the following indications:

• To confirm a suspicion of an abdominal or iliac aneurysm raised by a physical examination or noted as an incidental finding on another radiological examination. The physical examination usually reveals a palpable, pulsatile and nontender abdominal mass.
• To monitor the progression of an abdominal aortic aneurysm. It is usually expected that monitoring occurs approximately every six (6) months.
• To evaluate patients presenting with signs and symptoms of a thoracic aneurysm. The symptoms usually associated with a thoracic aneurysm are substernal chest pain, back or neck pain described as deep and aching or throbbing as well as symptoms due to pressure on the trachea (dyspnea, stridor, a brassy cough), the esophagus (dysphagia), the laryngeal nerve (hoarseness), or superior vena cava (edema in neck and arms, distended neck veins).
• To evaluate patients presenting with signs and symptoms of an abdominal aneurysm. The symptoms usually associated with an abdominal aneurysm are constant pain located in the midabdomen, lumbar region or pelvis which can be severe and may be described as having a boring quality. A leaking aneurysm is characterized by lower back pain, whereas, acute pain and hypotension usually occur with rupture.
• To evaluate a patient presenting with signs and symptoms suggestive of an aortic dissection. A patient with an aortic dissection has symptoms such as a sudden onset of severe, continuous tearing or crushing pain in the chest that radiates to the back and is generally unaccompanied by EKG evidence of a myocardial infarction. On physical examination, the patient is agitated, has a murmur of aortic regurgitation, asymmetric diminution of arterial pulses and systolic bruits over the areas where the aortic lumen is narrowed.
• Initial evaluation of a patient presenting with signs and symptoms such as intermittent claudication in the calf muscles, thighs and/or buttocks, rest pain, weakness in legs or feeling of tiredness in the buttocks, etc. which may suggest occlusive disease of the aorta and iliac arteries. The physical examination usually reveals decreased or absent femoral pulses, a bruit over the narrowed artery, and possibly muscle atrophy. If severe occlusive disease exists, the patient will have atrophic changes of the skin, thick nails, coolness of the skin with pallor and cyanosis.
• To evaluate patients suspected of an abdominal or thoracic arterial embolism or thrombosis. These patients usually present with severe pain in one or both lower extremities, numbness, and symmetric weakness of the legs, with absent or severely reduced pulses below the embolism site.
• To evaluate patients presenting with complaints of pain in the calf or thigh, slight swelling in the involved leg, tenderness of the iliac vein, etc. which may suggest phlebitis or thrombophlebitis of the iliac vein or inferior vena cava.
• To evaluate a patient who has sustained trauma to the chest wall and/or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.
• To assess the continued patency of both native venous and prosthetic arterial grafts following surgical intervention. Usually this is performed at 6 weeks, 3 months, then every six (6) months.
• To monitor the sites of various percutaneous interventions, including, but not limited to angioplasty, thrombolysis/thrombectomy, atherectomy, or stent placement. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

Limitations

Duplex testing should be reserved for specific indications for which the precise anatomic information obtained by this technique is likely to be useful. Therefore, it would be rare to see duplex scanning being performed for conditions in which another diagnostic test is recommended (e.g., an aortic dissection is better diagnosed with a chest x-ray, transesophageal echocardiogram or aortography).

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.