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Noninvasive Vascular Testing (NIVT): Medical Necessity Denials
Denial Reason, Reason/Remark Code(s)
- CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD
- CPT codes: 93880, 93922, 93923, 93970, 93971
Resolution/Resources
- Refer to the Local Coverage Determinations and Coverage Articles on the Palmetto GBA Web site:
- Noninvasive Vascular Testing (NIVT)
- Jurisdiction 1: Refer to the 'Noninvasive Cerebrovascular Studies: Noninvasive Peripheral Venous Studies' LCD at www.PalmettoGBA.com/J1b/LCD
- CPT codes 93875, 93922, 93923 and 93965 are complete bilateral studies. When the service is performed unilaterally, submit CPT modifier 52 (reduced services), and indicate 'unilateral' in the documentation record for electronic claims or as an attachment to the CMS-1500 claim form.
- Duplex post-interventional follow-up studies are usually limited in scope and unilateral in nature; therefore, the 'unilateral or limited study' codes should typically be used
- CPT modifier 50 (bilateral procedure) is not valid for CPT codes 93875 through 93971
- A quantity of 'one' must be used for a study of one anatomic area as described in the code definition
- The physiologic study will be denied as not medically necessary when CPT codes 93922 through 93923 and CPT codes 93925 through 93931 are submitted for the same date of service
- To document that it was medically necessary to perform both physiologic and duplex extremity examinations on the same day, both services must be submitted on the same claim and the claim must be submitted with one of the following ICD-9 codes: 442.0, 442.3, 442.82, 444.21, 444.22, 794.30, 903.00-904.9 or V58.73
- To document that it was medically necessary to perform venous duplex (CPT code 93970 or 93971) as surveillance of a patient at high risk for DVT due to immobility, trauma or surgical procedure, the service must be submitted with one of the following ICD-9 codes: V12.51, V12.52, V45.1, V45.81, V45.89, V67.00, V58.9 or V49.84
Advance Beneficiary Notice (ABN) Information
- If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an ABN prior to performing these tests
- ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'
- If you utilize ABNs, they must be issued in advance. Maintain the original in the patient's medical record. Provide the patient with a copy of the signed notice.
- ABNs must be issued using the standard CMS form. For services provided on or after March 1, 2009, you must use the revised CMS ABN if you are providing advance notice to the beneficiary. Access the revised ABN and other background information from the CMS Web site at www.cms.hhs.gov/BNI/01_overview.asp.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GA: