Is CPT code 93922 (Upper/Lower Extremity Arteriography, 2 levels) medically necessary for a patient with severe peripheral arterial disease and a non-healing wound?

Medical Necessity Determination for CPT 93922

CPT code 93922 (noninvasive physiological study of upper or lower extremity arteries, 2 levels) is medically necessary in this case, as the patient requires post-intervention surveillance following successful revascularization for critical limb ischemia (CLI) with tissue loss. 1

Clinical Context Supporting Medical Necessity

This 51-year-old male presents with critical limb ischemia meeting established diagnostic criteria 1:

• Chronic ischemic rest pain (I70.229 - atherosclerosis with rest pain) 1
• Nonhealing wound with 6-month progressive deterioration of plantar right foot wound 1
• Tissue loss and gangrene requiring fifth toe amputation with extensive osteomyelitis involving multiple metatarsals and tarsal bones 1
• Severe flow-limiting disease documented on angiography: 70-80% stenosis distal anterior tibial artery, 80-90% tandem stenoses posterior tibial/plantar arteries, dorsalis pedis occlusion 1
• Critical perfusion deficit with toe pressure of 0 mmHg (right) versus 65 mmHg (left) 1

Guideline-Based Rationale for Post-Intervention Surveillance

Long-term patency surveillance is a Class I recommendation for patients following lower extremity revascularization 1:

• The ACC/AHA guidelines explicitly state that "long-term patency of infrainguinal bypass grafts should be evaluated in a surveillance program, which should include an interval vascular history, resting ABIs, physical examination, and a duplex ultrasound at regular intervals" 1
• For endovascular interventions specifically, "long-term patency of endovascular sites may be evaluated in a surveillance program, which may include conducting exercise ABIs and other arterial imaging studies at regular intervals" 1

This patient underwent extensive endovascular intervention including balloon angioplasty of multiple tibial and pedal vessels with documented technical success 1. The ACC/AHA guidelines emphasize that duplex ultrasound is recommended for routine surveillance with minimum intervals at approximately 3,6, and 12 months, then yearly after intervention 1.

Why CPT 93922 is the Appropriate Test

Noninvasive physiological arterial studies (CPT 93922) serve as essential surveillance following CLI revascularization 1:

• Duplex ultrasound of the extremities is useful to diagnose anatomic location and degree of stenosis and is specifically recommended for post-intervention surveillance 1
• The 2024 ACC/AHA guidelines recommend resting ABI with or without ankle pulse volume recordings (PVR) and/or Doppler waveforms for establishing diagnosis and monitoring PAD 1
• Segmental pressures with PVR and/or Doppler waveforms are reasonable to help delineate the anatomic level of disease 1

CPT 93922 encompasses bilateral physiological studies at 2 levels, which is appropriate for:

• Monitoring patency of the multiple treated segments (anterior tibial, dorsalis pedis, deep plantar arch, lateral plantar, and posterior tibial arteries) 1
• Comparing the treated right lower extremity to the contralateral limb 1
• Detecting restenosis or progression of disease that could threaten wound healing 1

Critical Wound Healing Context

The ACC/AHA guidelines emphasize that coordinated surveillance is essential until complete wound healing is achieved 1:

• "The management of patients with CLI and nonhealing wounds should include coordinated efforts for both revascularization and wound healing, because the risk of limb-threatening infections remains until complete wound healing is achieved" 1
• "A comprehensive plan for treatment of CLI must include a plan for achieving an intact skin surface on a functional foot" 1
• One study demonstrated 100% limb salvage rate at 3 years in patients with CLI who achieved complete wound healing following revascularization 1

This patient has NOT achieved wound healing - he has extensive ongoing osteomyelitis involving multiple bones, fluid collections, and abnormal marrow signal [@clinical documentation]. The toe pressure remains 0 mmHg post-intervention, indicating persistent critical perfusion deficit requiring close monitoring [@6@].

Addressing the "No Criteria Listed" Issue

While MCG may not have specific criteria listed for CPT 93922 in isolation, the medical necessity is established through guideline-based post-revascularization surveillance protocols 1:

• The absence of MCG criteria does not negate medical necessity when Class I guideline recommendations support the intervention [@1@, 1]
• Post-intervention surveillance is standard of care to detect restenosis and prevent limb loss 1
• The patient meets high-risk criteria requiring intensive monitoring: diabetes with HbA1c 10.6, active osteomyelitis, extensive tissue loss, and critical baseline perfusion deficits [1, @6@]

Common Pitfalls to Avoid

Do not confuse diagnostic testing with surveillance testing - this is NOT an initial diagnostic study but rather post-intervention monitoring which has separate and distinct indications [@2@]:

• Initial diagnostic imaging (CTA 75710) was already performed and led to successful intervention [@clinical documentation]
• The revascularization procedures (CPT 37220-37230) have been completed [@clinical documentation]
• Current testing is for surveillance, which guidelines explicitly recommend [@2@]

Do not rely solely on ABI in diabetic patients - this patient requires comprehensive physiological assessment including segmental pressures and waveforms given his diabetes and noncompressible vessels [@6@, 1]:

• Patients with diabetes and CLI may have falsely elevated ABIs due to medial arterial calcification 1
• The initial toe pressure of 0 mmHg demonstrates the severity of disease that standard ABI alone would miss 1

Determination

CPT 93922 is MEDICALLY NECESSARY for this patient based on:

1. Class I guideline recommendation for post-revascularization surveillance [@2@]
2. Ongoing CLI with nonhealing wound requiring monitoring until complete wound healing [@1@, 1]
3. High-risk features (diabetes, extensive tissue loss, critical baseline perfusion) necessitating close surveillance 1
4. Standard of care to detect restenosis and prevent limb loss following complex tibial/pedal interventions [1, @15@]

The absence of specific MCG criteria for this CPT code does not override established Class I guideline recommendations from the ACC/AHA for post-intervention surveillance in CLI patients [@1