Latest Review Date: April 2024

Category: Medical                                                                 

POLICY:

Somatosensory evoked potentials (SEP, SSEP) or dermatosensory evoked potentials (DSEP) may be considered medically necessary for any of the following indications:

• Unexplained myelopathy;
• To localize the cause of a central nervous system deficit seen on exam, but not explained by lesions seen on CT or MRI;
• To identify clinically silent brain lesions in multiple sclerosis (MS) suspects in order to establish the diagnosis, where MS is suspected due to presence of suggestive neurologic symptoms plus one or more other objective findings (brain plaque on MRI, clinical lesions by history and physical examination, and/or positive CSF as determined by oligoclonal bands detected by established methods such as isoelectric focusing, different from any such bands in serum, or by an increased IgG index);
• To manage persons with spinocerebellar degeneration (e.g., Friedreich’s ataxia, olivopontocerebellar (OPC) degeneration);
• To assess any decline which may warrant emergency surgery in an unconscious person with a spinal cord injury who shows specific structural damage to the somatosensory system and is a candidate for emergency spinal cord surgery;
• To evaluate a person with suspected brain death.

Somatosensory evoked potentials (SEP, SSEP) or dermatosensory evoked potentials (DSEP) are considered investigational for all other indications, including but not limited to:

• SEP in conscious persons with severe spinal cord or head injuries, as the standard neurologic exam is the most direct way to evaluate any deficits;
• SEP in the diagnosis or management of amyotrophic lateral sclerosis (ALS);
• SEP in the diagnosis of cervical spondylitic myeloradiculopathy;
• SEP in the diagnosis or management of acquired metabolic disorders (e.g., lead toxicity, B12 deficiency);
• SEP in the diagnosis of thoracic outlet syndrome;
• SEP for the diagnosis of carpal tunnel syndrome/ulnar nerve entrapment;
• SEP for radiculopathies and peripheral nerve lesions where standard nerve conduction velocity studies are diagnostic.

Note:  Depending on the clinical condition being investigated, it may be medically necessary to test several nerves in one extremity and compare them with the opposite limb.

Documentation Requirements:  The physician’s SEP report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.

Visual evoked potentials (VEP) may be considered medically necessary for any of the following indications:

• To identify persons at increased risk for developing clinically definite multiple sclerosis;
• To diagnose or monitor multiple sclerosis (acute or chronic phases);
• To localize the cause of a visual field defect, not explained by lesions seen on CT or MRI, metabolic disorders, or infectious diseases;
• To evaluate signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons, etc.).

Visual evoked potentials (VEP) are considered investigational for all other indications, including for routine screening of infants.

Automated visual evoked potentials (VEP) are considered investigational.

Brain stem auditory evoked response (BAER), also known as brainstem auditory evoked potentials (BAEP) or auditory evoked potentials (AEP) may be considered medically necessary  for any of the following indications:

• To diagnose suspected acoustic neuroma;
• To assess recovery of brainstem function after a lesion compressing the brainstem has been surgically removed;
• To localize the cause of a central nervous system deficit seen on exam, but not explained by CT or MRI;
• To diagnose and monitor demyelinating and degenerative disease affecting the brain stem (e.g., central pontine myelinolysis, olivopontocerebellar (OPC) degeneration);
• To evaluate infants and children who have suspected hearing loss that cannot be effectively measured or monitored through audiometry;
• To screen infants and children under age 5 for hearing loss;

Note:  For purposes of neonatal screening, only limited auditory evoked potentials or limited evoked otoacoustic emissions may be considered medically necessary.  Neonates who fail this screening test are then referred for comprehensive auditory evoked response testing or comprehensive otoacoustic emissions.

• To assess brain death or profound metabolic coma in selected cases where diagnosis or outcome is unclear from standard tests (e.g., EEG);
• To diagnose post-meningitic deafness in children.

BAER is considered investigational when:

• As a test to identify persons at increased risk for developing clinically definite multiple sclerosis (CDMS).

Comprehensive auditory evoked response testing and comprehensive otoacoustic emissions are considered investigational for neonatal screening.

Miscellaneous Indications:

The following studies and indications are considered investigational:

• AEP to determine gestational age or conceptual age in pre-term neonates;
• Cognitive evoked potentials, also known as auditory or visual P300 or P3 cognitive evoked potentials, to diagnose cognitive dysfunction in persons with dementia (e.g., Alzheimer’s disease and Parkinson’s disease) or to identify the etiology of depression in persons with chronic demyelinating disease;
• Event-related potentials for the diagnosis of attention deficit/hyperactivity disorder or post-traumatic stress disorder, or assessment of brain injury, or evaluation of comatose persons;
• Gustatory evoked potentials for diagnosing taste disorders;
• Motor evoked potentials, other than for intraoperative use with SSEP;
• Cortical auditory evoked response (CAER) for the diagnosis of depression, attention deficit/hyperactivity disorder, autism, or any other indication;
• Vestibular evoked myogenic potentials (VEMP).

DESCRIPTION OF PROCEDURE OR SERVICE:

Evoked potentials are the electrical signals generated by the nervous system in response to sensory stimuli. The sensory system involved and the sequence of activation of different neural structures determines the timing and location of these signals. Because of their low voltage, evoked potentials generally are not discernible without computer averaging to differentiate them from ongoing EEG activity and other sources of electrical noise. Typically, it is necessary to present the stimulus repeatedly, averaging the time-locked brain or spinal cord responses to a series of identical stimuli, while allowing unrelated noise to average out. In the clinical setting, evoked potential studies are an extension of the neurological exam. They help reveal the existence and often suggest the location of neurological lesions. Evoked potentials are most useful when they detect clinically silent abnormalities that might otherwise go unrecognized, or when they assist in resolving vague or equivocal symptoms and findings. Evoked potential studies are tests of function.  The findings usually are not etiologically specific. These types of evoked potentials are routinely performed: somatosensory, visual, and brainstem auditory.

Somatosensory Evoked Potentials (SSEP or SEP)

Somatosensory evoked potentials consist of a series of waves that reflect sequential activation of neural structures along the somatosensory pathways. The noninvasive clinical studies are performed by the repetitive, submaximal, electrical stimulation of a sensory or mixed sensorimotor peripheral nerve and recording the averaged responses from electrodes placed over proximal portions of the nerve stimulated, plexus, spine, and scalp. Amplitude, peak and interpeak latency measurements with side-to-side comparisons are used to assess abnormalities. SEP are used to aid in the determination of a diagnosis. SEP can also be performed by stimulating the skin in dermatomal areas (DSEP). The evoked potential response depends on the functional integrity of the nerve that is stimulated. SEP are an extension of the electrodiagnostic evaluation and are used to evaluate nerves that cannot be studied by conventional nerve conduction studies, including electromyography. An abnormal SEP points to a problem in the nerve conduction mechanism that carries the impulse to the brain. However, the SEP abnormality is not disease specific; an abnormal SEP indicates impairments associated with certain disorders. An abnormal SEP signifies an impaired pathway, helps to localize it, and provides a prognostic guide. The SEP does not provide any indication about the nature of the underlying pathological processes.

SEP are altered by impairment of the somatosensory pathway which may occur because of both diffuse (e.g., disease of myelin, hereditary system degenerations, coma) or local disorders (e.g., tumors, vascular lesions). SEP abnormalities can be detected in a variety of different settings. The electrophysiologic findings should be interpreted in the clinical context in which they are obtained (e.g., assessing functional integrity, diagnostic purposes, determining the course of neurological disorders, determining pathological involvement). SEP are helpful in evaluating ill-defined complaints. SEP may detect clinically silent brain lesions in multiple sclerosis suspects. Although SEP abnormalities alone are insufficient to establish the diagnosis of MS, the diagnosis can be established when there are other objective findings, such as brain plaques on MRI, clinical lesions by history and physical exam, and/or positive CSF findings (as determined by oligoclonal bands detected by established methods such as isoelectric focusing, different from any such bands in serum, or by an increased IgG index). A physician assesses the individual and determines a preliminary differential diagnosis. SEP testing may then be performed by a trained technologist under the direct supervision of a physician. Direct supervision implies that a physician is in close proximity to the patient undergoing testing, is immediately available to provide the trained technician with assistance and direction if necessary, and is responsible for determining the SEP studies that are appropriate.

Recordings of SEP can be normal even in individuals with extreme sensory deficits due to the presence of multiple, parallel, afferent somatosensory pathways. This procedure is often performed to investigate individuals with MS; various coma states, such as those from post-traumatic injury or post-anoxia; suspected brain death; and to indicate the extensiveness of lesion damage in spinal cord injuries. The return of a cortically generated response to stimulation of a nerve below the injured portion of the cord, indicates an incomplete lesion and, therefore, may offer a better prognosis.

SEP testing is typically performed bilaterally. Depending on the clinical situation being investigated, several nerves in one extremity may have to be tested and compared with the opposite limb. The physician’s SEP report should indicate which nerves were tested, latencies at various testing points, and an evaluation of whether the results were normal or abnormal.

Visual Evoked Potentials (VEP)

Visual-evoked potentials (VEP), also known as visual-evoked responses (VER), are brain waves resulting from light stimuli. VEP are used to track visual signals from the retina to the occipital cortex. With electrodes placed at occipital and parietal locations of the scalp, a checkerboard pattern is projected on a screen and rapidly reversed 100 times at a rate of once or twice per second. The procedure is performed on each eye. Occasionally, checkerboard pattern testing is difficult to use in infants or older patients, so a stroboscopic flash stimulus is used. This type of testing is severely limited due to the great variability of responses among normal persons and its relative insensitivity to clinical lesions. Visual neural impulses from either method are recorded as they travel from the eye to the occipital cortex. VEP are abnormal in patients with optic neuritis or multiple sclerosis.

Brain Stem Auditory Evoked Potentials (BAEP)

Brain stem auditory evoked potentials (BAEP), also known as auditory evoked potentials (AEP) or brain stem auditory evoked responses (BAER), are brain waves resulting from sound stimuli. A brief stimulus such as a sharp click is given to one ear through an earphone, while hearing in the opposite ear is masked with white noise to prevent its stimulation by transcranially-conducted sound. After the acoustic stimulus, signals are generated in the auditory nerve and brainstem.

Depending on the amount of time elapsed between the click stimulus and the auditory evoked response, potentials are classified as early (0 to 10 msec), middle (11 to 50 msec), or late (51 to 500 msec). The early potentials reflect electrical activity at the cochlea, eighth cranial nerve, and brain stem levels. The latter potentials reflect cortical activity. In order to separate evoked potentials from background noise, a computer averages the auditory evoked responses to 1000 to 2000 clicks. Early evoked responses may be analyzed to estimate the magnitude of hearing loss and to differentiate among cochlea, eighth nerve, and brainstem lesions.

Sensitivity and specificity reports for these tests vary. There is no clearly established measure of comparison in the medical literature, making comparisons across studies difficult. Interobserver differences, the variety of tests employed, the presence of symptoms that may influence patient outcomes, such as pain, and the presence of abnormal imaging studies in asymptomatic patients, and the subjectivity of the physician’s interpretations may all lead to variances in sensitivity and specificity results. Despite these variances, electrodiagnostic testing is commonly used to assist in diagnosing disorders involving the nerves, muscles, and neuromuscular junction.

Vestibular Evoked Myogenic Potential Testing

Vestibular evoked myogenic potential (VEMP) tests are newer techniques that use loud sound (e.g., click, tone burst) or bone vibration (e.g., tendon hammer tap to the forehead or mastoid) to assess otolith function. Both the saccule and utricle are sensitive to sound as well as vibration and movement.

Cervical VEMPs are measured by surface electrodes on the ipsilateral sternocleidomastoid muscle in the neck and are thought to originate primarily in the saccule. Abnormality in any part of the auditory cervical VEMP pathway (saccule, inferior vestibular nerve, vestibular nucleus, medial vestibulospinal tract, the accessory nucleus, the eleventh nerve, and sternocleidomastoid) can affect the response.

Ocular VEMPs detect subtle activity of an extraocular muscle using surface electrodes under the contralateral eye during an upward gaze and are thought to be due primarily to stimulation of the utricle. The vestibulo-ocular reflex stimulated by sound or vibration is very small, but synchronous bursts of activity of the extraocular muscles can be detected by electromyography. Lesions that affect the ocular VEMP may occur in the utricle, superior vestibular nerve, vestibular nucleus, and the crossed vestibulo-ocular reflex pathways.

KEY POINTS:

The most recent literature update was performed through April 12, 2024. 

Summary of Evidence

For individuals with unexplained myelopathy, clinical silent brain lesions in multiple sclerosis, suspected brain death, spinocerebellar degeneration, and central nervous system deficits seen on exam, but not explained by lesions on CT or MRI utilize somatosensory evoked potentials or dermatosensory evoked potentials to evaluate these disease processes, the evidence includes a meta-analysis and systematic reviews. Relevant outcomes are overall survival, morbid events, treatment-related mortality [or morbidity], symptoms, functional outcomes, and quality of life. It has been reported that SSEPs have a high sensitivity in MS patients. Studies have shown that there is a statistically significant increase of SSEP abnormalities the P22 wave is extended in individuals diagnosed with MS. Also, studies have shown SSEP is a supportive ancillary test with or without an EEG, to confirm brain death in suspected spinal cord injury or neuromuscular injury. The evidence is sufficient to determine the effects of the technology on health outcomes.

For individuals with increased risk for developing clinical definite multiple sclerosis, to diagnose or monitor individuals with multiple sclerosis (acute or chronic), and vision loss in unresponsive individuals utilize visual evoked potentials to evaluate these disease processes, the evidence includes a prospective study and a systemic review.  Relevant outcomes are overall survival, morbid events, treatment-related mortality [or morbidity], symptoms, and functional outcomes. Studies have shown VEPs with abnormal latency results, due to the myelin plaques and demyelinating optic neuropathy slow the speed of VEP wave peaks individuals with MS. The evidence is sufficient to determine the effects of the technology on health outcomes.

For individuals who have suspected acoustic neuroma, infants and children who have suspected hearing loss that cannot be effectively measured or monitored through audiometry, and to assess an individual’s recovery of brainstem function after a lesion compressing the brainstem has been surgically removed, the evidence includes prospective study, systematic review, and meta-analysis. Studies have shown the use of brainstem-evoked response audiometry is beneficial in detecting hearing loss compared to the use of pure tone audiograms in individuals with cochlear damage and central auditory nervous system disorders. The evidence is sufficient to determine the effects of the technology on health outcomes.

For individuals who have suspected vestibular disorders and otolith dysfunction in benign paroxysmal positional vertigo (BPPV) who receive VEMP testing, the evidence includes systemic review and meta-analysis. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. Researchers  indicate that well-designed studies with large samples, normal control groups, and uniform parameters of VEMP testing are needed to further examine the otolith dysfunction of BPPV individuals. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Audiology

The 2009 American Academy of Audiology has a position statement on the audiologist’s role in the diagnosis and treatment of vestibular disorders. Citing a 2009 scope of practice report, the Academy stated that "An audiologist is a person who, by virtue of academic degree, clinical training, and license to practice and/or professional credential, is uniquely qualified to provide a comprehensive array of professional services related to the prevention of hearing loss and the audiologic identification, assessment, diagnosis, and treatment of persons with impairment of auditory and vestibular function, and to the prevention of impairments associated with them." Evaluations of vestibular and extravestibular systems may include:

• Video-oculography, videonystagmography, and electronystagmography
• Tests of dynamic visual acuity,
• Tests of active and passive rotation,
• Tests of postural stability, and
• Tests of vestibular evoked myogenic potentials.

Vestibular treatment and therapy protocols that fall within the scope of practice are also described. The Academy considers vestibular function testing following treatment to be an essential part of the clinical practice.

American Academy of Neurology

The 2017 practice guidelines from AAN assessed the diagnostic value of vestibular evoked myogenic potential testing in individuals with vestibular symptoms. The conditions of interest included superior canal dehiscence syndrome, vestibular neuritis or migraine, Meniere disease, and benign paroxysmal positional vertigo (BPPV). The evidence for testing in BPPV was drawn from two class III studies, neither of which presented sufficient diagnostic value of vestibular evoked myogenic potential testing for the treatment to be recommended (level C evidence).

International Federation of Clinical Neurophysiology

A 2014 expert consensus document on cervical vestibular evoked myogenic potential methods from the International Federation of Clinical Neurophysiology has stated that the clinical use of vestibular evoked myogenic potential “is evolving and questions still exist about its physiology and measurement.”

KEY WORDS:

Somatosensory evoked potentials (SEP, SSEP), visual evoked potentials (VEP), brain stem auditory evoked potentials (BAEP, brainstem auditory evoked response (BAER), auditory evoked potentials (AEP), dermatosensory evoked potentials (DSEP), automated VEP, Diopsys NOVA VEP, Enfant VEP System, Vestibular evoked myogenic potentials , VEMP, Automated visual evoked potentials,  Comprehensive auditory evoked response testing, comprehensive otoacoustic emissions, Cognitive evoked potentials, visual P300, P3 cognitive evoked potentials, Event-related potentials, Gustatory evoked potentials, Motor evoked potentials, Cortical auditory evoked response, CAER

APPROVED BY GOVERNING BODIES:

The United States Food and Drug Administration (FDA) has approved several types of evoked potential devices for marketing by the FDA through the 510(k) process. There are automated visual evoked potentials for visual acuity screening, evoked response systems, and nerve stimulators/monitors  (e.g., SmartEP). An example of such a device is the Enfant® Pediatric VEP (Doisy’s Corp., Metuchen, NJ), “a non-invasive medical device to screen, without dilation or sedation, for visual disorders in infants and pre-school children. The system uses visual evoked potentials to provide information about the visual pathway function and optical or neural abnormalities related to vision.”

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

CURRENT CODING:

CPT Codes:

REFERENCES:

1. American Academy of Audiology. Scope of practice. April 2023. www.audiology.org/practice-guideline/scope-of-practice.
2. American Academy or Audiology. Position statement on the audiologist's role in the diagnosis & treatment of vestibular disorders. n.d.; www.audiology.org/publications-resources/document-library/position-statement-audiologists-role-diagnosis-treatment.
3. American Academy of Neurology.  Assessment:  Dermatomal somatosensory evoked potentials.  American Academy of Neurology.  Therapeutics and Technology Assessment Subcommittee.  Neurology 1997; 49(4): 1127-1130. 
4. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Position Statement - Recommended Policy for Electrodiagnostic Medicine. Updated Jan 2023. www.aanem.org.
5. American Clinical Neurophysiology Society. Guideline 9A: Guidelines on evoked potentials. J Clin Neurophysiol. 2006; 23(2):125-137. www.aanem.org.
6. American Clinical Neurophysiology Society. Guideline 9B: Guidelines on visual evoked potentials. J Clin Neurophysiol. 2006; 23(2):138-156. www.aanem.org.
7. American Clinical Neurophysiology Society. Guideline 9D: Guidelines on short-latency somatosensory evoked potentials. J Clin Neurophysiol. 2006; 23:168–179. www.aanem.org
8. American Academy of Ophthalmology. Glaucoma Diagnosis. www.aao.org/eye-health/diseases/glaucoma-diagnosis.
9. American Academy of Neurology.  Practice parameters: Determining brain death in adults (Summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995; 45:1012-1014.
10. Barton JJS. Benign paroxysmal positional vertigo. In: Wilterdink JL, ed. UpToDate. : Waltham, MA: UpToDate. 2024.
11. Bower C, Reilly BK, Richerson J, et al; AAP Committee on Practice & Ambulatory Medicine. Hearing Assessment in Infants, Children, and Adolescents: Recommendations Beyond Neonatal Screening. Pediatrics. 2023;152(3):e2023063288. doi.org/10.1542/peds.2023-
12. Chen G, Dai X, Ren X, et al. Ocular vs. cervical vestibular evoked myogenic potentials in benign paroxysmal positional vertigo: A systematic review and meta-analysis. Front Neurol. 2020 Oct 26;11:596454.
13. Creel DJ. Visually Evoked Potentials. 2012 Mar 01. In: Kolb H, Fernandez E, Nelson R, editors. Webvision: The Organization of the Retina and Visual System [Internet]. Salt Lake City (UT): University of Utah Health Sciences Center; 1995. www.ncbi.nlm.nih.gov/books/NBK107218/pdf/CreelVEP.pdf.
14. Cruccu G, et al. Recommendations for the clinical use of somatosensory-evoked potentials. Clinical Neurophysiology, August 2008; 119(8): 1705-1719.
15. Gronseth GS and Ashman EJ. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in patients with suspected multiple sclerosis (an evidence-based review). Neurology 2000; 54: 1720-1725.
16. Elman LB. Diagnosis of amyotrophic lateral sclerosis and other forms of motor neuron disease. In:  Goddeau RP, ed. UpToDate. Waltham, Mass.: UpToDate, 2024.
17. Fife TD, Satya-Murti S, Burkard RF, Carey JP. Vestibular evoked myogenic potential testing: Payment policy review for clinicians and payers. Neurol Clin Pract. 2018;8(2):129-134. doi:10.1212/CPJ.
18. Goldman RH. Lead exposure, toxicity, and poisoning in adults. In: Ganetsky M, ed. UpToDate. Waltham, Mass.: UpToDate, 2024.
19. Halmagyi G, Curthoys IS. Otolith Function Tests. In: Herdman SJ, Clendaniel RA. eds. Vestibular Rehabilitation, 4e. F. A. Davis Company; 2014. Accessed April 04, 2024. fadavispt.mhmedical.com/content.aspx?bookid=1878&sectionid=140996328Halmagyi G, Curthoys IS. Otolith function tests.
20. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
21. Joint Committee on Infant Hearing. Year 2007 position statement: Principles for early hearing detection and intervention programs. Pediatrics, October 2007, Vol. 120, No. 4, pp. 897-921.
22. (2019) Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Journal of Early Hearing Detection and Intervention, 4(2), 1-44. DOI: doi.org/10.15142/fptk-b748
23. Kanji A, Khoza-Shangase K, Moroe N. Newborn hearing screening protocols and their outcomes: A systematic review. Int J Pediatr Otorhinolaryngol. 2018;115:104-109. doi:10.1016/j.ijporl.2018.09.026
24. Koenig MA, Kaplan PW. Brain death. Handb Clin Neurol. 2019;161:89-102. doi:10.1016/B978-0-444-64142-7.00042-4
25. Leocani, L., Guerrieri, S., & Comi, G. (2018). Visual Evoked Potentials as a Biomarker in Multiple Sclerosis and Associated Optic Neuritis. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society, 38(3), 350–357. doi.org/10.1097/WNO.0000000000000704
26. Loncarevi AN, et al. Somatosensory evoked potentials (SSEP) in multiple sclerosis. Medicinski Arkiv, January 2008; 62(2): 80-81.
27. Multiple sclerosis in adults: management. London: National Institute for Health and Care Excellence (NICE); 2022 Jun 22. (NICE Guideline, No. 220.) www.ncbi.nlm.nih.gov/books/NBK585280/
28. National Multiple Sclerosis Society. Diagnosing MS. www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-MS.
29. Means RT. Causes and pathophysiology of vitamin B12 and folate deficiencies. In: Tirnauer J, ed. UpToDate. Waltham, Mass.:UpToDate , 2024.
30. Opal P. Friedreich ataxia. In: Eicler AF, ed. UpToDate. Waltham, Mass.: UpToDate 2024
31. Oya R, Imai T, Takenaka Y, et al. Clinical significance of cervical and ocular vestibular evoked myogenic potentials in benign paroxysmal positional vertigo: A meta-analysis. Eur Arch Otorhinolaryngol. 2019; 276(12):3257-3265.
32. Papathanasiou ES, Murofushi T, Akin FW, et al. International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: an expert consensus report. Clin Neurophysiol. Apr 2014; 125(4): 658-666.
33. Sand T, Kvaløy MB, Wader T, Hovdal H. Evoked potential tests in clinical diagnosis. Tidsskr Nor Laegeforen. 2013; 133(9):960-965.
34. Siow SF, Cameron Smail R, Ng K, et al. Motor evoked potentials in hereditary spastic paraplegia-a systematic review. Front Neurol. 2019; 10:967.
35. Smith R. Hearing loss in children: screening and evaluation. In: Armsby C, ed.UpToDate. Waltham, Mass. : UpToDate, 2024.
36. Soleimani M, Rouhbakhsh N, Rahbar N. Towards early intervention of hearing instruments using cortical auditory evoked potentials (CAEPs): A systematic review. Int J Pediatr Otorhinolaryngol. 2021;144:110698. doi:10.1016/j.ijporl.2021.110698
37. van Laerhoven H, de Haan TR, Offringa M, et al. Prognostic tests in term neonates with hypoxic-ischemic encephalopathy: a systematic review. Pediatrics. 2013; 131(1):88-98.
38. US Food and Drug Administration. 510(k) Premarket Notification. US Department of Health and Human Services website. www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm
39. United States Food and Drug Administration, Summary of Safety and Effectiveness 510(k), K043491, Enfant® Pediatric VEP (Diopsys Corp., Metuchen, NJ).
40. United States Food and Drug Administration, Summary of Safety and Effectiveness 510(k), K101763, Diopsys TM NOVA VEP Vision Testing System (Diopsys Corp., Metuchen, NJ).
41. U.S. Preventive Services Task Force. Universal screening for hearing loss in newborns recommendation statement. Pediatrics 2008; 122: 143-148.
42. Verrecchia L, Brantberg K, Tawfique Z, et al. Diagnostic Accuracy of Ocular Vestibular Evoked Myogenic Potentials for Superior Canal Dehiscence Syndrome in a Large Cohort of Dizzy Patients. Ear Hear. Mar/Apr 2019; 40(2): 287-294.

POLICY HISTORY:

Medical Policy Group, March 2010 (2)

Medical Policy Group, April 2010 (2)

Medical Policy Administration Committee May 2010

Available for comment May 7-June 21, 2010

Medical Policy Group, December 2011 (3): Added new 2012 Codes – 95938 & 95939

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

Medical Policy Group, June 2013 (1) Updated policy statement for VEP section stating automated VEP testing is investigational; added new code 0333T related to automated VEP testing to policy effective for 7/1/2013; added automated VEP, Diopsys NOVA VEP, and Enfant VEP System to Key Words

Medical Policy Administration Committee June 2013

Available for comment May 30 through July 13, 2013

Medical Policy Group, December 2016: 2017 Annual Coding Update. Added new CPT code 0464T to current coding.

Medical Policy Group, December 2017. Annual Coding Update 2018. Updated verbiage for revised codes 95930 and 0333T.

Medical Policy Group, January 2018 (6): Updated Key Words to include : Vestibular evoked myogenic potentials , VEMP, Automated visual evoked potentials,  Comprehensive auditory evoked response testing, comprehensive otoacoustic emissions, Cognitive evoked potentials, visual P300, P3 cognitive evoked potentials, Event-related potentials, Gustatory evoked potentials, Motor evoked potentials, Cortical auditory evoked response, CAER. Added 92700 to Coding Section. No change to policy statement.

Medical Policy Group, November 2019 (3): 2019 Updates to Key Points. A peer reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.

Medical Policy Group, October 2020 (3): 2020 Updates to Key Points. A peer reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.

Medical Policy Group, November 2020 (3): Annual Coding Update.  Added CPT codes: 92517, 92518, 92519, 92650, 92651, 92652, and 92653 to the Current coding section. Created Previous Coding section to include codes: 92585 and 92586.

Medical Policy Panel, February 2021

Medical Policy Group, March 2021 (3): 2021 Updates to Description, Key Points, and References. Added Practice Guidelines and Position Statements section referencing AAN recommendations for VEMP. Policy statement updated to remove “not medically necessary.” Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, March 2022 (3): 2022 Updates to Key Points. Reviewed by consensus. No new literature identified that would alter the coverage statement of this policy.

Medical Policy Group, March 2023 (3): 2023 Updates to Key Points, Benefit Applications, and References. Removed Previous Coding Section. Reviewed by consensus. No new literature identified that would alter the coverage statement of this policy.

Medical Policy Group, April 2024 (3): Updates to Key Points, Approved by Governing Bodies, Current CPT coding section, and References. Reviewed by consensus. No new literature identified that would alter the coverage statement of this policy.

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.