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MP 6.01.07 Transcranial Doppler Ultrasound

 

Medical Policy    
Section
Radiology
Original Policy Date
5/30/97
Last Review Status/Date
Reviewed with literature search/April 2006
Issue
2:2006
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


 

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 3 primary sites (or acoustic windows): 1) the temporal bone along the orbitomeatal line, 2) the foramen magnum at the base of the skull, and 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;
  • as a tool to determine risk for transient ischemic attacks (TIA) or cardiovascular accidents (CVA) in patients with sickle cell disease.

Transcranial Doppler ultrasound is 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; and
  • 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.

 


 

Policy Guidelines

No applicable information

 


 

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, Florida (http://www.hnionline.com/Default.htm).

 


 

Rationale

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

  • monitoring for vasospasm in patients with subarachnoid hemorrhage
  • intraoperative assessment and monitoring of collateral blood flow and embolizations in patients undergoing carotid endarterectomy
  • evaluation of patients with transient ischemic attacks or cerebrovascular accidents for intracranial artery stenosis
  • 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 above, 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% of total hemoglobin; children received transfusions every 3 to 4 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. AdamsRJ, 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.

 

Codes

Number

Description

CPT  93886  Transcranial Doppler study of the intracranial arteries; complete study 
  93888  Follow-up or limited study 
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   
Type of Service  Radiology 
Place of Service  Inpatient
 
Outpatient
 

 


 

Index

Doppler Ultrasound, Transcranial (TCD)
TCD (Transcranial Doppler Ultrasound)
Transcranial Doppler Ultrasound (TCD)
Ultrasound, Transcranial Doppler (TCD)

 


 

Policy History

Date Action Reason
05/30/97 Add to Radiology section New policy
07/16/99 Replace policy Revised; new indications for sickle cell disease
04/15/02 Replace policy Policy reviewed without literature review; new review date only
04/29/03 Replace policy Policy reviewed without literature review; new review date only
04/25/06 Replace policy Policy reviewed with literature review focused on vasodilator therapy for developmental and behavioral disorders. New policy statement added that TCD monitoring of this indication for vasodilator therapy is considered investigational. Rationale section now addresses this topic; 1994 TEC Assessment added to reference list.