Latest Review Date: April 2024

Category: Medical                                                                 

POLICY:

Vestibular autorotation test (VAT) is considered investigational for all indications, including but not limited to the diagnosis of individuals with vestibular disorders.

DESCRIPTION OF PROCEDURE OR SERVICE:

Impairment of the vestibular-ocular reflex (VOR) may result in chronic dizziness and imbalance. The VAT is a high frequency, active head rotation (AHR) test to subjectively evaluate the VOR and its function. Individuals wear a lightweight head-strap with a velocity sensor on the back. They follow instructions to shake their head, first side-to-side, and then up-and-down. Conventional electro-olfactogram electrodes placed around the eyes measure individuals' eye movements.

Although some published studies have suggested that the VAT may be useful in evaluating individuals with vestibular disorders/diseases, few studies examined the sensitivity and specificity of the VAT in evaluating individuals with suspected vestibular abnormalities. Furthermore, there is a lack of data supporting the value of the VAT in the management of patients with vestibular disorders/diseases.

Additional drawbacks of the VAT include (i) slippage of the head velocity sensor at high frequencies and accelerations during testing, (ii) contribution of the cervico-ocular reflex to the compensatory eye movement response, and this contribution may be increased significantly in the presence of bilateral, peripheral vestibular pathology, (iii) results of different head autorotation tests may not be directly comparable, and (iv) poor test-retest reliability.

KEY POINTS:

The most recent literature update was performed through April 15, 2024.

Summary of Evidence:

Review of available literature shows that vestibular autorotation test (VAT) for the diagnosis of individuals with vestibular disorders, vestibular migraine, or any other indications is lacking. The  sensitivity, specificity, reproducibility, and clinical utility have not been demonstrated. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

KEY WORDS:

Vestibular autorotation test (VAT), vestibular ocular reflex (VOR), Vorteq system, Epley maneuver, active head rotation (AHR), vestibular migraine, Meniere's Disease

Practice Guidelines and Position Statements:

No practice guidelines identified.

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

CPT Codes:

There is no specific code for the vestibular autorotation test (VAT).

REFERENCES:

1. Barbosa F, Villa TR. Vestibular migraine: Diagnosis challenges and need for targeted treatment. Arq Neuropsiquiatr. 2016;74(5):416-422.
2. Della Santina CC, Cremer PD, Carey JP, et al. Comparison of head thrust test with head autorotation test reveals that the vestibulo-ocular reflex is enhanced during voluntary head movements. Arch Otolaryngol Head Neck Surg, 2002; 128(9): 1044-1054.
3. Fife TD, Tusa RJ, Furman JM, et al. Assessment: Vestibular testing techniques in adults and children: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 2000; 55(10): 1431-1441.
4. Guo N, Zhou L, Zhang Y, Fan X. Vestibular autorotation test: The differences in peripheral and central acute vestibular syndrome. Evid Based Complement Alternat Med. 2022;2022:8180013.
5. Hsieh LC, Lin TM, Chang YM, et al. Clinical applications of correlational vestibular autorotation test. Acta Otolaryngol. 2015; 135(6):549-556.
6. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
7. Liu D, Guo ZQ, Tian E, et al. Dynamic changes of vestibular autorotation test in patients with unilateral vestibular dysfunction during rehabilitation. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2022;57(3):270-275.
8. Liu D, Wang J, Tian E, et al. Diagnostic value of the vestibular autorotation test in Meniere's disease, vestibular migraine and Meniere's Disease with migraine. Brain Sci. 2022;12(11):1432.
9. López Escámez JA, Molina MI, et al. Oculomotor response to the vertical cephalic autorotatory test in patients with benign paroxistic positional vertigo of the posterior canal. Acta Otorrinolaringol Esp. 2006; 57(5): 210-216.
10. Nachum Z, Gordon CR, Shahal B, et al. Active high-frequency vestibulo-ocular reflex and seasickness susceptibility. Laryngoscope, 2002; 112(1): 179-182.
11. Ozgirgin ON, Tarhan E. Epley maneuver and the head autorotation test in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol, 2008 Mar 26. [Epub ahead of print].
12. Robertson CE. Vestibular migraine. UpToDate Inc., Waltham, MA. Last reviewed February 2018.
13. Thungavelu Y, Wang W, Lin P, et al. The clinical utility of vestibular autorotation test in patients with vestibular migraine. Acta Otolaryngol. 2017;137(10):1046-1050.
14. Tirelli G, Bigarini S, Russolo M, et al. Test-retest reliability of the VOR as measured via Vorteq in healthy subjects. Acta Otorhinolaryngol Ital, 2004; 24(2): 58-62.
15. Wang W, Yogun T, Chen TS, et al. The characteristics and clinical significance of vestibular autorotation test in patients with vestibular migraine. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2018;53(12):909-913.
16. Yao Y, Zhao Z, Qi X, et al. cVEMP and VAT for the diagnosis of vestibular migraine. Eur J Clin Invest. 2022;52(1):e13657.

POLICY HISTORY:

Medical Policy Group, October 2008 (3)

Medical Policy Administration Committee, November 2008

Available for comment October 23-December 8, 2008

Medical Policy Group, October 2010 (1) Key points updated, no policy statement change

Medical Policy Group, September 2012 (3): Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, November 2015: 2016 Annual Coding Update.  Added new CPT codes 92537 and 92538 to the current coding section.  Created a previous coding section and moved cpt code 92543 from current coding to previous coding.

Medical Policy Group, November 2019 (6): Updates to Description, Key Points and References. No change to policy intent.

Medical Policy Group, December 2019 (6): 2020 Annual Coding Update, Revised code 92548, added code 92549.

Medical Policy Group, March 2021(3): 2021 Updates to Key Points. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Policy statement updated to remove “not medically necessary.”

Medical Policy Group, March 2022 (3): 2022 Updates to Key Points. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, March 2023 (6): Updates to Key Points, Benefit Application, Key Words (vestibular migraine) and References.

Medical Policy Group, April 2024 (9): Reviewed by consensus. Updates to Key Points and References. Key Words added- "Meniere’s Disease." Added CPT code 92700 to Coding Section. No change in Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.