CAM 60107

Transcranial Doppler Ultrasound

Category:Radiology   Last Reviewed:May 2019
Department(s):Medical Affairs   Next Review:May 2999
Original Date:May 1997    

Description:
Transcranial Doppler ultrasound (TCD) is a non-invasive modality for imaging blood flow in cerebral arteries and veins.

In TCD, ultrasonic waves are generated by a probe placed over the skull. The bony plate of the skull limits TCD measurements to three primary sites (or acoustic windows). These are:

  1. The temporal bone along the orbito-meatal line
  2. The foramen magnum at the base of the skull
  3. The optic foramina

Sound waves transmitted through these windows are reflected by blood cells in the intracranial vasculature. The frequency shift of the reflected sound waves recorded at the probe is used to estimate blood flow velocity or flow volume.

Policy:
Transcranial Doppler ultrasound may be considered MEDICALLY NECESSARY for:

  • Monitoring for vasospasm in patients with subarachnoid hemorrhage
  • Assessing initial collateral blood flow and embolization during carotid endarterectomy to detect severe ischemia so that a shunt can be placed to reduce the risk of stroke
  • Assessment of patients suspected of having steno-occlusive disease of the intracranial arteries
  • Determining risk for transient ischemic attacks (TIA) or cardiovascular accidents (CVA) in patients with sickle cell disease

Transcranial Doppler ultrasound may be considered INVESTIGATIONAL for:

  • Evaluating the hemodynamic significance of extracranial vascular atherosclerosis
  • Detection and assessment of the circulatory patterns of arteriovenous malformations
  • Evaluating cerebral blood flow after trauma
  • Assessing cerebral circulatory arrest as a measure of brain death
  • Assessing migraine and tension headaches
  • Assessing the adequacy of cerebral blood flow and embolic events during cardiopulmonary bypass surgery
  • Evaluating blood flow patterns in central nervous system infections
  • Evaluating dementia
  • Assessing hydrocephalus
  • Evaluating glaucoma
  • Monitoring vasodilator therapy as a treatment of behavior or developmental disorders including, but not limited to, attention deficit hyperactivity disorder (ADHD), autism or Tourette's syndrome

Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved devices may be assessed on the basis of their medical necessity.

Transcranial Doppler ultrasound for monitoring vasodilator therapy as a treatment of behavioral or developmental disorders appears to be primarily offered by the Hammesfahr Neurological Institute in Clearwater, FL (http://www.hnionline.com/Default.htm).

Rationale:
This policy is based in part on a 1994 TEC Assessment (1) that evaluated these indications for transcranial Doppler:

  1. Monitoring for vasospasm in patients with subarachnoid hemorrhage
  2. Intraoperative assessment and monitoring of collateral blood flow and embolizations in patients undergoing carotid endarterectomy
  3. Evaluation of patients with transient ischemic attacks or cerebrovascular accidents for intracranial artery stenosis
  4. Evaluation of patients who have sickle cell disease without symptoms of transient ischemic attack (TIA) or cerebrovascular accident (CVA) for intracranial artery stenosis

The TEC Assessment concluded that for the first two indications listed, transcranial Doppler met the TEC criteria, while indications 3 and 4 did not. It should be noted that the 1994 TEC Assessment also considered the recommendations of a 1990 policy statement issued by the American Academy of Neurology. (2)

The current policy updates the fourth indication (i.e., transcranial Doppler in patients with sickle cell disease) based on additional randomized controlled studies. Specifically, in 1998, Adams and colleagues reported on a trial of chronic blood transfusions in 130 children with sickle cell anemia and abnormal results on TCD. (3) An abnormal TCD was defined as 200 cm per second in either the internal carotid artery or the middle cerebral artery. A total of 63 patients were randomized to receive transfusions to achieve a target hemoglobin S concentration of less than 30 percent of total hemoglobin. Children received transfusions every three to four weeks. The remaining 67 patients received standard care. There was a significant decrease in the incidence of stroke in the transfusion group, leading to premature termination of the trial. This trial did not address how long transfusion should be continued as a means of preventing stroke or at what intervals repeated TCD is warranted. Despite the positive results of the trial, chronic transfusion therapy presents its own set of risks that may limit enthusiasm for this approach. For example, treatment of iron overload will likely be required. In addition, the overall safety of the blood supply is a concern. (4)

2006 Update:
This policy update is focused on the role of TCD as a technique to monitor vasodilator therapy in patients with developmental or behavioral disorders. It has been hypothesized that these disorders are related to cerebral vasospasm that can be relieved by vasodilator therapy. However, a search of the MEDLINE database failed to identify any peer-reviewed articles focused on this therapy.

References:

  1. 1994 TEC Assessment, Tab 20.
  2. American Academy of Neurology Therapeutics and Technology Assessment Subcommittee. Assessment: transcranial Doppler. Neurology 1990; 40(4):680-1.
  3. Adams RJ, McKie VC, Hsu L et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med 1998; 339(1):5-11.
  4. Cohen AR. Sickle cell disease new treatments, new questions. N Engl J Med 1998; 339(1):42-4.

Coding Section

Codes Number Description
CPT 93886 Transcranial Doppler study of the intracranial arteries; complete study
  93888 ; limited study
  93890 ; vasoreactivity study
  93892 ; emboli detection without intravenous microbubble injection
  93893 ; emboli detection with intravenous microbubble injection
ICD-9 Procedure 88.71 Diagnostic ultrasound of head and neck
ICD-9 Diagnosis 282.6

Sickle cell disease

  430 Subarachnoid hemorrhage
  434.0 Cerebral thrombosis
  434.1 Cerebral embolism
  437.0 Cerebral atherosclerosis
  852.0 Subarachnoid hemorrhage following injury, without mention of open intracranial wound
  852.1 Subarachnoid hemorrhage following injury, with open intracranial wound
HCPCS No Code  
ICD-10-CM (effective 10/01/15)   D571 Sickle-cell disease without crisis
   D5700 Hb-SS disease with crisis, unspecified 
   D5720 Sickle-cell/Hb-C disease without crisis 
   D57219 Sickle-cell/Hb-C disease with crisis, unspecified 
   D5780 Other sickle-cell disorders without crisis 
   D57819 Other sickle-cell disorders with crisis, unspecified 
  I609 Nontraumatic subarachnoid hemorrhage, unspecified 
  I6609 Occlusion and stenosis of unspecified middle cerebral artery
  I6619 Occlusion and stenosis of unspecified anterior cerebral artery
  I6629 Occlusion and stenosis of unspecified posterior cerebral artery
  I6330 Cerebral infarction due to thrombosis of unspecified cerebral artery
  I6340  Cerebral infarction due to embolism of unspecified cerebral artery 
  I6350  Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery 
  I669 Occlusion and stenosis of unspecified cerebral artery
  I672 Cerebral atherosclerosis
  S066X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter
  S066X1A  Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
  S066X2A  Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter
  S066X3A  Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
  S066X4A  Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
  S066X5A  Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
  S066X6A  Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
  S066X7A  Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
  S066X8A  Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
  S066X9A  Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter
  S0190XA Unspecified open wound of unspecified part of head, initial encounter
Type of Service Radiology  
Place of Service Inpatient/Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

05/08/2019 

Annual review, no change to policy intent 

05/21/2018 

Annual review, no change to policy intent. 

05/23/2017 

Annual review, no change to policy intent. 

05/03/2016 

Annual review, no change to policy intent. 

05/04/2015 

Annual review, no change to policy intent. Added benefit applications and coding.

05/26/2014

Annual review. No changes made.


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