CAM 034

Visual and Auditory Evoked Potentials

Category:Medicine   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:June 2013    

Description:
Sensory evoked potentials (SEP) are electrical waves that are generated by the response of sensory neurons to stimuli. Changes in the electrical waves are averaged by a computer and then interpreted by a physician. Computer averaged SEPs can be used to assist the diagnosis of certain neuropathologic states or to provide information for treatment management. Two methodologies of monitoring are visual evoked potential (VEP) and auditory evoked potential (AEP).

Visual evoked potential is used to track visual signals from the retina to the occipital cortex light flashes. It has been used for surgery on lesions near the optic chiasm. VEP can be difficult to interpret due to their sensitivity to anesthesia, temperature and blood pressure.

Auditory evoked potential is also called auditory brainstem response (ABR). It is an electrophysiologic measure of auditory function that utilizes responses produced by the auditory nerve and the brainstem and helps differentiate sensory from neural hearing loss. The response is the waveform averaged over many auditory clicks. Auditory evoked potentials may be used for screening purposes in very young children.

Vestibular evoked myogenic potential (VEMP) testing, also known as click evoked neurogenic vestibular potential testing, is a noninvasive, neurophysiological test used to determine the function of vestibular organs in the inner ear, specifically the utricle and saccule. VEMP testing has been investigated in the diagnosis and management of several disorders, including superior canal dehiscence, benign paroxysmal positional vertigo, Ménière's disease, vestibular schwannoma, vestibular neuritis, otosclerosis and multiple sclerosis.

The test measures a muscle reflex evoked by stimulation of the vestibular organs and recorded from electrodes placed on the skin over tensed sternocleidomastoid muscles in the neck (cervical VEMP) or over extraocular muscles beneath the eyes (ocular VEMP). Vestibular stimulation is performed using a loud sound or vibration. Variations in the response of the muscle to the vestibular stimulation, such as absent or decreased electrical activity in the muscle, have been associated with certain disorders.

The U.S. Food and Drug Adminstration (FDA) has not approved specific devices for VEMP testing. Commercially available auditory brainstem response (ABR) equipment can be adapted to perform VEMP testing.

Policy:

  • Visual and auditory evoked potential recordings are considered MEDICALLY NECESSARY if the medical appropriateness criteria are met.
  • Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered INVESTIGATIONAL.
  • Vestibular evoked myogenic potential (VEMP) testing is considered INVESTIGATIONAL for all indications due to the lack of clinical evidence demonstrating its impact on improved health outcomes.

Policy Guidelines:
Visual and auditory evoked potential recordings are considered MEDICALLY APPROPRIATE if ANY ONE of the following criteria are met:

  • Visual evoked potentials (VEP) for ANY ONE of the following:
    • To diagnose and monitor the course of multiple sclerosis (MS). This includes recordings made in the acute phase to disclose the presence of active demyelinating plaques. This also includes recording in the chronic phase to disclose the presence of subclinical plaques.
    • To localize the basis for visual field defects, which occur in the absence of structural lesions, acquired metabolic disease or infectious disease.
  • Auditory evoked potentials (AEP), also known as Brain Stem Auditory Evoked Response (BAER) for ANY ONE of the following:
    • To evaluate brainstem function in acquired metabolic disorders, e.g., hypoxic encephalopathy.
    • To use as a second-line test to disclose the presence of brainstem tumor if MRI or CT does not reveal a tumor or lesion to be present as indicated by clinical examination. Also to disclose the presence of a brainstem tumor if MRI or CT is not available.
    • To diagnose and monitor the course of demyelinating or degenerative diseases of the brainstem (e.g., MS, central pontine myelinolysis and olivopontocerebellar degeneration).
    • To diagnose the presence of lesions in the auditory system external to the brainstem (e.g., acoustic neuromas).
    • To assess recovery of brainstem function after removal of space occupying lesions compressing the brainstem.
    • To supplement the EEG in evaluating the irreversibility of coma or brain death.
    • To measure the type and extent of hearing impairment or determine the degree of neural maturation in neonates, infants and children less than five years of age; applies to screening for hearing impairment in children less than five years of age. (Age listings are intended as a guideline for members who have no other developmental or physical impairment.)

Rationale:
Evoked potentials measure conduction velocities of sensory pathways in the central nervous system using computerized averaging techniques. Three types of evoked potentials are routinely performed: (i) somatosensory; (ii) visual; and (iii) brainstem auditory. In each of these tests, a peripheral sense organ is electrically stimulated and conduction velocities are recorded for central somatosensory pathways located in the posterior columns of the spinal cord, brain stem and thalamus, and the primary sensory cortex located in the parietal lobes. This policy addresses Visual and Brain Stem Auditory Evoked Potentials.

For patients with symptomatic nerve root compression, the accurate identification of the particular nerve root(s) that are causing symptoms is an essential prerequisite to surgical intervention. The history and physical examination may be helpful in identifying the particular peripheral nerve root that is affected, but these are often inconclusive. Patients often have difficulty defining the distribution of pain or sensory symptoms, and the physical examination may be completely normal even in patients with severe pain. Imaging studies may be helpful, but are frequently normal or reveal abnormalities of uncertain clinical relevance. Moreover, because structural abnormalities are commonly seen in imaging studies of normal asymptomatic middle-aged or elderly subjects, it is difficult to determine whether any such abnormalities that are identified in pain patients are related to their symptoms. In addition, imaging studies may show equivocal changes or anatomic abnormalities at multiple levels, making it impossible to determine which nerve root is responsible for the patient's symptoms. In these circumstances, evoked potentials may be used to measure nerve root function and thereby more accurately identify the precise nerve roots responsible for the patient’s symptoms.

Studies have demonstrated a statistically significant association between abnormal visual evoked potentials (VEPs) and an increased risk of developing clinically definite multiple sclerosis (CDMS). In these studies, patients with suspected MS were 2.5 to nine times as likely to develop CDMS as patients with normal VEPs. Visual evoked potentials sensitivities ranged from 25 percent to 83 percent. Visual evoked potentials improved the ability to predict which MS suspects will develop CDMS by as much as 29 percent.

Measurement of visual evoked responses (VERs) is the primary means of objectively testing vision in infants and young children suspected of having disorders of the visual system, where the child is too young to report differences in color vision or to undergo assessment of visual fields and visual acuity. A flashing stroboscope or an alternating checkerboard pattern is presented, and the wave patterns are recorded. In an infant, vision may be reliably tested using a flashing light during quiet sleep. Lesions affecting the visual pathways can be localized by noting the presence of decreased amplitudes or increased latencies of VERs, and by determining whether VER abnormalities involve one or both eyes. Visual evoked responses are also useful for testing vision in other persons who are not able to communicate.

Brain stem auditory evoked responses (BAERs) are electrical potentials that are produced in response to an auditory stimulus and are recorded from disk electrodes attached to the scalp. 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, 8th 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 1,000 to 2,000 clicks. Early evoked responses may be analyzed to estimate the magnitude of hearing loss and to differentiate among cochlea, 8th nerve and brainstem lesions.

The clinical utility of BAER over standard auditory testing is due to several of BAER's characteristics: (i) BAER's resistance to alteration by systemic metabolic abnormalities, medications or pronounced changes in the state of consciousness of the patient; and (ii) the close association of BAER waveform abnormalities to underlying structural pathology. Brain stem auditory evoked responses have been proven effective for differentiating conductive from sensory hearing loss, for detecting tumors and other disease states affecting central auditory pathways (e.g., acoustic neuromas) and for noninvasively detecting hearing loss in patients who cannot cooperate with subjective auditory testing (e.g., infants, comatose patients). BAER is the test of choice to assess hearing in infants and young children. It is most useful for following asphyxia, hyperbilirubinemia, intracranial hemorrhage or meningoencephalitis or for assessing an infant who has trisomy. BAER also is useful in the assessment of multiple sclerosis or other demyelinating conditions, coma or hysteria. Audiometric analysis using multiple sound frequencies is usually preferred over BAER for testing hearing in cooperative patients who are able to report when sounds are heard. Evidence is insufficient at this time to recommend BAER as a useful test to identify patients at increased risk for developing CDMS.

Studies of cognitive evoked potentials (also known as the P300 or P3 cognitive evoked potentials) have been used in research settings to correlate changes in cognitive evoked potentials with clinical changes in cognitive function in patients with dementia (e.g., Alzheimer's disease and Parkinson's disease) and identify the etiology of depression in patients with chronic demyelinating disease. However, there is insufficient evidence regarding the effectiveness of cognitive evoked potential studies in diagnosing or rendering treatment decisions that would affect health outcomes. Furthermore, there is a lack of studies comparing cognitive evoked potential studies with standard neuropsychiatric and psychometric tests used in diagnosing cognitive dysfunction.

The American Academy of Pediatrics (AAP) Task Force on Newborn and Infant Hearing and the Joint Committee on Infant Hearing (JCIH) endorse the implementation of universal newborn hearing screening. Screening should be conducted before discharge from the hospital whenever possible. Physicians should provide recommended hearing screening, not only during early infancy but also through early childhood for those children at risk for hearing loss (e.g., history of trauma, meningitis) and for those demonstrating clinical signs of possible hearing loss.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for hearing loss in all newborns. All infants should be screened before one month of age. Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before three months of age for confirmatory testing. Because of the elevated risk of hearing loss in infants with risk indicators (e.g., neonatal intensive care unit admission for two or more days; syndromes associated with hearing loss, such as Usher syndrome and Waardenburg syndrome; family history of hereditary childhood hearing loss; craniofacial abnormalities; and congenital infections such as cytomegalovirus, toxoplasmosis, bacterial meningitis, syphilis, herpes and rubella), an expert panel recommends that these children undergo periodic monitoring for three years. The USPSTF found good evidence that newborn hearing screening leads to earlier identification and treatment of infants with hearing loss and improves language outcomes. However, additional studies detailing the correlation between childhood language scores and functional outcomes (e.g., school attainment and social functioning) are needed.

Two types of tests are commonly used to screen for congenital hearing loss: (i) otoacoustic emissions (OAEs) and (ii) auditory brainstem response (ABR) (Helfand et al. 2001). Otoacoustic emissions testing evaluates the integrity of the inner ear (cochlea). In response to noise, vibrations of the hair cells in a healthy inner ear generate electrical responses, known as otoacoustic emissions. The absence of OAEs indicates that the inner ear is not responding appropriately to sound. Transient evoked otoacoustic emissions (TEOAEs) are generated in response to wide-band clicks, while distortion product otoacoustic emissions (DPOAE) are a response to tones. Both stimuli are presented via a lightweight ear canal probe. A microphone picks up the signal, and multiple responses are averaged to get a specific repeatable waveform. Otoacoustic emissions are used in screening and diagnosis of hearing impairments in infants, and in young children and patients with cognitive impairments (e.g., mental retardation, dementia) who are unable to respond reliably to standard hearing tests. Otoacoustic emissions are also useful for evaluating patients with tinnitus, suspected malingering and for monitoring cochlear damage from ototoxic drugs.

The ABR is an electrophysiological response generated in the brainstem in response to auditory signals and composed of either clicks or tones. The stimulus is delivered via earphones or an inserted ear probe, and scalp electrodes pick up the signal. Auditory brainstem response evaluates the integrity of the peripheral auditory system and the auditory nerve pathways up to the brainstem and is able to identify infants with normal cochlear function but abnormal 8th-nerve function (auditory neuropathy). For purposes of neonatal screening, a limited ABR is performed in the nursery using a significantly low intensity level (35 to 40 dB) to rule out marked hearing loss (Schwartz and Schwartz, 1990; Scott and Bhattacharyya, 2002). If testing at this level fails to elicit a response, the infant is referred to an audiologic laboratory for a comprehensive ABR, involving testing at many different intensity levels.

Typically, screening programs use a two-stage screening approach (either OAE repeated twice, OAE followed by ABR or ABR repeated twice). Criteria for defining a "pass" or "fail" on the initial screening test vary widely. Comprehensive (diagnostic) OAEs or ABRs are used to diagnose hearing impairments identified by limited (screening) tests.

Auditory brainstem response and OAE have limitations that affect their accuracy in certain patients. Both require a sleeping or quiet child. Middle-ear effusion or debris in the external canal can compromise the accuracy of these tests. Otoacoustic emissions and ABR test the peripheral auditory system and 8th nerve pathway to the brainstem, respectively. They are not designed to identify infants with central hearing deficits. Therefore, infants with risk factors for central hearing deficits, particularly those who have congenital Cytomegalovirus infection or prolonged severe hypoxia at birth, may pass their newborn hearing screens with either OAE or ABR, but develop profound hearing loss in early infancy.

The newer generation of automated screeners are easy to use and do not require highly trained staff. However, equipping hospitals with equipment and sufficient staff can be costly, the staff must be trained to understand the limitations of the techniques and ongoing quality control is essential to achieve accurate, consistent test results. The importance of technique is illustrated by the results of multicenter studies of universal screening, in which the rates of false positive and technically inadequate examinations varied 10-fold among sites.

There are differences between the guidelines with respect to the screening technology that is endorsed. The Joint Committee on Infant Hearing recommends that all infants have access to screening using a physiologic measure (either otoacoustic emissions [TEOAE or DPOAE] and/or ABR). The AAP states that although additional research is necessary to determine which screening test is ideal, EOAE and/or ABR are presently the screening methods of choice. The AAP defers recommending a preferred screening test. The USPSTF recommends a one- or two-step validated protocol, stating that OAEs followed by ABR in those who failed the first test is a frequently used protocol. Well-maintained equipment, thoroughly trained staff and quality control programs are also recommended to avoid false-positive tests.

References:

  1. American Academy of Neurology. (2005, October) Practice parameter: Evaluation of the child with global development delay.
  2. American Academy of Neurology. (2008, August) Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in patients with suspected multiple sclerosis (an evidence-based review).
  3. American Clinical Neurophysiology Society. (2006, February). Guideline 9a: Guidelines on evoked potentials.
  4. American Clinical Neurophysiology Society. Guideline 9b: Guidelines on visual evoked potentials. Journal of Clinical Neurophysiology, 23 (2) 138-156.
  5. BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2005). Evaluation of hearing impairment- Archived. (9.01.02).
  6. BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2011). Intra-operative neurophysiologic monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring).
  7. Complete Guide to Medicare Coverage Issues [Computer software]. (2011, November). Evoked response tests (NCD 160.10, p. 2-81). Ingenix.
  8. Odom, J., Bach, M., Brigell, M., Holder, G., McCulloch, D., Tormene, A., et al. (2010). ISCEV standard for clinical visual evoked potentials (2009 update). Documenta Ophthalmologica. Advances in Ophthamology, 120 (1), 111-119.
  9. U. S. Food and Drug Administration. (2002, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K021895.
  10. U. S. Food and Drug Administration. (2005, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K043491.
  11. Walsh, P. Kane, N., & Butler, S. (2005). The clinical role of evoked potentials. Journal of Neurology, Neurosurgery, Psychiatry. 2005 (7), 16-22.
  12. Medical Services Advisory Committee (MSAC). Oto-acoustic emission audiometry. Final Assessment Report. MSAC Application 1002. Canberra, ACT: MSAC; 1999.
  13. American Academy of Pediatrics. Joint committee on infant hearing 1994 position statement. American Academy of Pediatrics Joint Committee on Infant Hearing. Pediatrics. 1995;95(1):152-156.
  14. McClelland RJ, Watson DR, Lawless V, et al. Reliability and effectiveness of screening for hearing loss in high risk neonates. BMJ. 1992;304(6830):806-809.
  15. Stapells DR, Kurtzberg D. Evoked potential assessment of auditory system integrity in infants. Clin Perinatol. 1991;18(3):497-518.
  16. Hyde ML, Riko K, Malizia K. Audiometric accuracy of the click ABR in infants at risk for hearing loss. J Am Acad Audiol. 1990;1(2):59-66.
  17. Acoustic Neuroma Association (ANA). Detection and diagnosis of acoustic neuromas. [Web Site]. Atlanta, GA: ANA, 1998.
  18. Gronseth GS, Ashman EJ. Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in patients with suspected multiple sclerosis (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;54(9):1720-1725.
  19. Rothstein TL. The role of evoked potentials in anoxic-ischemic coma and severe brain trauma. J Clin Neurophysiol. 2000;17(5):486-497.
  20. Medical Services Advisory Committee (MSAC). Visual electrodiagnosis. MSAC Application 1005. Canberra, ACT: MSAC; 2001.
  21. Reeves RR. The effects of donepezil on the P300 auditory and visual cognitive evoked potentials of patients with Alzheimer's disease. Am J Geriatr Psychiatry. 1999;7:349-352.
  22. Erenberg A, Lemons J, Sia C, Trunkel D, Ziring P. Newborn and infant hearing loss: Detection and intervention. American Academy of Pediatrics. Task Force on Newborn and Infant Hearing, 1998-1999. Pediatrics. 1999;103(2):527-530.
  23. Joint Committee on Infant Hearing. Year 2000 position statement. Principles and guidelines for early hearing detection and intervention programs. Am J Audiol. 2000;9(1):9-29.
  24. Helfand M, Thompson DC, Davis R, et al. Newborn hearing screening. Systematic Evidence Review Number 5. Contract 290-97-0018 to the Oregon Health & Science University Evidence-based Practice Center, Portland, Oregon. AHRQ Publication No. 02-S001. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); October 2001.
  25. Schwartz DM, Schwartz JA. Auditory evoked potentials in clinical pediatrics. In: Hearing Assessment. 2nd ed. WF Rintelmann, ed. Austin, TX: ProEd Press Publishers; 1990.
  26. Scott ME, Bhattacharyya N. Auditory brainstem response audiometry. eMedicine J. 2002;3(5).
  27. Anyanwu E, Campbell AW, High W. Brainstem auditory evoked response in adolescents with acoustic mycotic neuroma due to environmental exposure to toxic molds. Int J Adolesc Med Health. 2002;14(1):67-76.
  28. Cone-Wesson B, Wunderlich J. Auditory evoked potentials from the cortex: Audiology applications. Curr Opin Otolaryngol Head Neck Surg. 2003;11(5):372-377.
  29. National Collaborating Centre for Chronic Conditions. Multiple sclerosis. National clinical guideline for diagnosis and management in primary and secondary care. London, UK: National Institute for Clinical Excellence (NICE); 2004.
  30. Cunningham M, Cox EO. Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics. 2003;111(2):436-440.
  31. U.S. Preventive Services Task Force. Universal screening for hearing loss in newborns: U.S. Preventive Services Task Force Recommendation Statement. Pediatrics. 2008;122(1):143–148.
  32. American Academy of Ophthalmology. Policy Statement. Vision screening for infants and children. A Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology. March 2007.
  33. U.S. Preventive Services Task Force. Screening for visual impairment in children ages one to five years. January 2011.
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Coding Section

Codes Number Description
CPT 95930 Visual Evoked Potentials
  92585-92586 Auditory Evoked Potentials
  92700  Unlisted otorhinolaryngological service or procedure  
ICD-9 Diagnosis 340

diagnosis and monitoring of multiple sclerosis (MS), acute or chronic phases

 

368.40, 368.43, 368.44, 368.46, 368.47

localizing the cause of a visual field defect, not explained by lesions seen on CT or MRI, metabolic disorders, or infectious diseases

 

240.0 - 279.9

evaluate brainstem function in acquired metabolic disorders
 

191.7, 198.3, 225.0, 237.5, 239.6

assess recovery of brainstem function after a lesion compressing the brainstem has been surgically removed

 

781.99, 436

localizing the cause of a neurologic deficit seen on exam, not explained by lesions seen on CT or MRI

 

340, 341.8, 333.0

diagnosis and monitoring of demyelinating and degenerative diseases affecting the brain stem (MS, central pontine myelinolysis, olivopontocerbellar degeneration and others)

 

173.2, 160.1, 192.0, 147.2, 197.3, 198.2, 198.4, 198.89, 210.7, 212.0, 216.2, 225.1, 230.0, 231.8, 232.2, 235.1, 235.9, 237.9, 238.2, 239.0, 239.1, 239.2, 239.7, 386.10, 386.11, 386.12, 386.19

diagnosis of lesions in the auditory system

 

070.0, 070.20, 070.21, 070.22, 070.23, 070.41, 070.42, 070.43, 070.44, 070.49, 070.6, 250.20, 249.20, 249.21, 249.30, 249.31, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 251.0, 348.8, 572.2, 779.2, 780.01, 780.02

evaluation of the irreversibility of coma or brain death, along with an EEG

 

379.54, 386.00, 386.01, 386.02, 386.03, 386.04, 388.12, 389.00, 389.01, 389.02, 389.03, 389.04, 389.05, 389.06, 389.08, 389.10, 389.11, 389.12, 389.13, 389.14, 389.15, 389.16, 389.17, 389.18, 389.20, 389.21, 389.22, 389.2, 389.7, 389.8, 389.9, 744.00, 744.01, 744.02, 744.03, 744.04, 744.05, 744.09

differentiate sensory from neural hearing loss (ICD-9 codes 379.54, 386.00, 386.01, 386.02, 386.03, 386.04, 744.00, 744.01, 744.02, 744.03, 744.04, 744.05, 744.09 (added 10-20-2004) (ICD-9 code 389.2 (deleted 9-30-2007) (ICD-9 codes 389.14, 389.18, 389.7 [description revised 10-1-2007) (ICD-9 codes 389.17, 389.20, 389.21, 389.22 (new 10-1-2007)) (ICD-9 codes 389.05, 389.06, 389.15, 389.16 (added 1-9-2008)

ICD-10-CM (effective 10/01/15) C8118 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of multiple sites
  G35 Multiple Sclerosis 
  E010 Iodine-deficiency related diffuse (endemic) goiter
  E011 Iodine-deficiency related multinodular (endemic) goiter
  E012 Iodine-deficiency related (endemic) goiter, unspecified 
  E018 Other iodine-deficiency related thyroid disorders and allied conditions
  E030 Congenital hypothyroidism with diffuse goiter
  E031 Congenital hypothyroidism without goiter
  E040 Nontoxic diffuse goiter
  E042 Nontoxic multinodular goiter
  E048 Other specified nontoxic goiter
  E049 Nontoxic goiter, unspecified
  E060 Acute thyroiditis
  E061 Subacute thyroiditis
  E0500 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
  E0501 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
  E0520 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm
  E0521 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm
  E071 Dyshormogenetic goiter
  E0789 Other specified disorders of thyroid
  P720 Neonatal goiter, not elsewhere classified
  P722 Other transitory neonatal disorders of thyroid function, not elsewhere classified
  E089  Diabetes mellitus due to underlying condition with other diabetic kidney complication
  E0839 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication 
  E0849  Diabetes mellitus due to underlying condition with other diabetic neurological complication
  E0869 Diabetes mellitus due to underlying condition with other specified complication
  E0929 Drug or chemical induced diabetes mellitus with other diabetic kidney complication
  E0930 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication
  E0940  Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication 
  E0969  Drug or chemical induced diabetes mellitus with other specified complication
  E1029  Type 1 diabetes mellitus with other diabetic kidney complication
  E1039  Type 1 diabetes mellitus with other diabetic ophthalmic complication
  E1049  Type 1 diabetes mellitus with other diabetic neurological complication 
  E1069  Type 1 diabetes mellitus with other specified complication
  E1129  Type 2 diabetes mellitus with other diabetic kidney complication 
  E1139  Type 2 diabetes mellitus with other diabetic ophthalmic complication 
  E1149  Type 2 diabetes mellitus with other diabetic neurological complication 
  E1169  Type 2 diabetes mellitus with other specified complication 
  E1329 Other specified diabetes mellitus with other diabetic kidney complication 
  E1339  Other specified diabetes mellitus with other diabetic ophthalmic complication
  E1349  Other specified diabetes mellitus with other diabetic neurological complication 
  E1369 Other specified diabetes mellitus with other specified complication 
  E15  Nondiabetic hypoglycemic coma 
  E210  Primary hyperparathyroidism
  E211 Secondary hyperparathyroidism, not elsewhere classified
  E212 Other hyperparathyroidism  
  E213 Hyperparathyroidism, unspecified 
  N2581 Secondary hyperparathyroidism of renal origin 
  C751  Malignant neoplasm of pituitary gland
  D352  Benign neoplasm of pituitary gland 
  D443  Neoplasm of uncertain behavior of pituitary gland 
  E228  Other hyperfunction of pituitary gland 
  E229  Hyperfunction of pituitary gland, unspecified 
  E236  Other disorders of pituitary gland 
  E237  Disorder of pituitary gland, unspecified 
  C37  Malignant neoplasm of thymus 
  C7A091 Malignant carcinoid tumor of the thymus 
  D150 Benign neoplasm of thymus 
  D384 Neoplasm of uncertain behavior of thymus 
  D3A091 Benign carcinoid tumor of the thymus 
  E320 Persistent hyperplasia of thymus 
  E321 Abscess of thymus 
  E328 Other diseases of thymus 
  E329 Disease of thymus, unspecified 
  E278  Other specified disorders of adrenal gland
  E279  Disorder of adrenal gland, unspecified 
  E242  Drug-induced Cushing's syndrome 
  E248  Other Cushing's syndrome 
  E249  Cushing's syndrome, unspecified 
  E2609  Other primary hyperaldosteronism 
  E261  Secondary hyperaldosteronism 
  E2689  Other hyperaldosteronism 
  E269  Hyperaldosteronism, unspecified 
  E288  Other ovarian dysfunction 
  E289  Ovarian dysfunction, unspecified 
  E298  Other testicular dysfunction 
  E299  Testicular dysfunction, unspecified 
  E310  Autoimmune polyglandular failure 
  E311  Polyglandular hyperfunction 
  E318  Other polyglandular dysfunction 
  E319  Polyglandular dysfunction, unspecified 
  E3120  Multiple endocrine neoplasia [MEN] syndrome, unspecified
  E3121  Multiple endocrine neoplasia [MEN] type I 
  E3122 Multiple endocrine neoplasia [MEN] type IIA 
  E3123  Multiple endocrine neoplasia [MEN] type IIB 
  E348 Other specified endocrine disorders
  E35  Disorders of endocrine glands in diseases classified elsewhere 
  E8989  Other postprocedural endocrine and metabolic complications and disorders 
  E43 Unspecified severe protein-calorie malnutrition
  E440  Moderate protein-calorie malnutrition
  E441  Mild protein-calorie malnutrition 
  E45  Retarded development following protein-calorie malnutrition 
  E46  Unspecified protein-calorie malnutrition 
  E640 Sequelae of protein-calorie malnutrition
  E500  Vitamin A deficiency with conjunctival xerosis
  E501  Vitamin A deficiency with Bitot's spot and conjunctival xerosis 
  E502 Vitamin A deficiency with corneal xerosis
  E503  Vitamin A deficiency with corneal ulceration and xerosis
  E504  Vitamin A deficiency with keratomalacia 
  E505 Vitamin A deficiency with night blindness
  E506  Vitamin A deficiency with xerophthalmic scars of cornea 
  E507  Other ocular manifestations of vitamin A deficiency 
  E508  Other manifestations of vitamin A deficiency 
  E509  Vitamin A deficiency, unspecified 
  E641 Sequelae of vitamin A deficiency
  E518  Other manifestations of thiamine deficiency
  E519  Thiamine deficiency, unspecified 
  E52 Niacin deficiency [pellagra]
  E5111  Dry beriberi 
  E5112  Wet beriberi 
  E559  Vitamin D deficiency, unspecified 
  E550  Rickets, active 
  E643  Sequelae of rickets 
  E561  Deficiency of vitamin K 
  E708  Other disorders of aromatic amino-acid metabolism
  E709  Disorder of aromatic amino-acid metabolism, unspecified 
  E7119  Other disorders of branched-chain amino-acid metabolism 
  E712  Disorder of branched-chain amino-acid metabolism, unspecified 
  E7200  Disorders of amino-acid transport, unspecified 
  E7209  Other disorders of amino-acid transport 
  E7210  Disorders of sulfur-bearing amino-acid metabolism, unspecified 
  E7219  Other disorders of sulfur-bearing amino-acid metabolism 
  E728  Other specified disorders of amino-acid metabolism 
  E729  Disorder of amino-acid metabolism, unspecified 
  E700  Classical phenylketonuria 
  E7439  Other disorders of intestinal carbohydrate absorption
  E748  Other specified disorders of carbohydrate metabolism 
  E7881 Lipoid dermatoarthritis 
  R779  Abnormality of plasma protein, unspecified 
  D890  Polyclonal hypergammaglobulinemia 
  M109  Gout, unspecified
  E8389  Other disorders of mineral metabolism
  E839  Disorder of mineral metabolism, unspecified 
  E83110 Hereditary hemochromatosis 
  E83111  Hemochromatosis due to repeated red blood cell transfusions 
  E83118  Other hemochromatosis 
  E83119  Hemochromatosis, unspecified 
  E8300  Disorder of copper metabolism, unspecified 
  E8309  Other disorders of copper metabolism 
  E8310  Disorder of iron metabolism, unspecified 
  E8319  Other disorders of iron metabolism 
  E8340  Disorders of magnesium metabolism, unspecified
  E8349  Other disorders of magnesium metabolism 
  E8330  Disorder of phosphorus metabolism, unspecified 
  E8339  Other disorders of phosphorus metabolism 
  E8350  Unspecified disorder of calcium metabolism 
  E8359  Other disorders of calcium metabolism 
  E8351  Hypocalcemia 
  E8352  Hypercalcemia 
  E8350  Unspecified disorder of calcium metabolism 
  E8359  Other disorders of calcium metabolism 
  E8381  Hungry bone syndrome 
  E8389  Other disorders of mineral metabolism 
  E839  Disorder of mineral metabolism, unspecified 
  E878  Other disorders of electrolyte and fluid balance, not elsewhere classified 
  E870  Hyperosmolality and hypernatremia 
  E840  Cystic fibrosis with pulmonary manifestations 
  E8411  Meconium ileus in cystic fibrosis 
  E8419  Cystic fibrosis with other intestinal manifestations 
  E848  Cystic fibrosis with other manifestations 
  E849  Cystic fibrosis, unspecified 
  E6601 Morbid (severe) obesity due to excess calories 
  E6609  Other obesity due to excess calories 
  E661  Drug-induced obesity 
  E662  Morbid (severe) obesity with alveolar hypoventilation 
  E668  Other obesity 
  E669  Obesity, unspecified 
  D8989  Other specified disorders involving the immune mechanism, not elsewhere classified 
  D899  Disorder involving the immune mechanism, unspecified 
  D800  Hereditary hypogammaglobulinemia 
  D801  Nonfamilial hypogammaglobulinemia 
  D802 Selective deficiency of immunoglobulin A [IgA] 
  C717 Malignant neoplasm of brain stem
  C718 Malignant neoplasm of overlapping sites of brain
  C719 Malignant neoplasm of brain, unspecified
  D496 Neoplasm of unspecified behavior of brain
  I6789 Other cerebrovascular disease
  I679 Cerebrovascular disease, unspecified 
  G378  Other specified demyelinating diseases of central nervous system 
  G2589  Other specified extrapyramidal and movement disorders
  G259 Extrapyramidal and movement disorder, unspecified 
  G26  Extrapyramidal and movement disorders in diseases classified elsewhere 
  C44291  Other specified malignant neoplasm of skin of unspecified ear and external auricular canal
  C44292  Other specified malignant neoplasm of skin of right ear and external auricular canal 
  C44299  Other specified malignant neoplasm of skin of left ear and external auricular canal 
  C300 Malignant neoplasm of nasal cavity
  Z8522 Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses 
  C112  Malignant neoplasm of lateral wall of nasopharynx 
  C7839  Secondary malignant neoplasm of other respiratory organs 
  C792  Secondary malignant neoplasm of skin 
  C7949  Secondary malignant neoplasm of other parts of nervous system 
  C7989  Secondary malignant neoplasm of other specified sites
  D106 Benign neoplasm of nasopharynx
  D140  Benign neoplasm of middle ear, nasal cavity and accessory sinuses 
  D2320  Other benign neoplasm of skin of unspecified ear and external auricular canal 
  D3333  Benign neoplasm of cranial nerves 
  D0000  Carcinoma in situ of oral cavity, unspecified site
  D0008 Carcinoma in situ of pharynx
  D040  Carcinoma in situ of skin of lip 
  D023  Carcinoma in situ of other parts of respiratory system 
  C148  Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx 
  D385  Neoplasm of uncertain behavior of other respiratory organs 
  D438 Neoplasm of uncertain behavior of other specified parts of central nervous system 
  D485  Neoplasm of uncertain behavior of skin 
  D490  Neoplasm of unspecified behavior of digestive system 
  D491  Neoplasm of unspecified behavior of respiratory system
  D492  Neoplasm of unspecified behavior of bone, soft tissue, and skin 
  D497  Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system 
  H81399  Other peripheral vertigo, unspecified ear 
  H8110  Benign paroxysmal vertigo, unspecified ear 
  H8120  Vestibular neuronitis, unspecified ear 
  H81399  Other peripheral vertigo, unspecified ear 
  B179  Acute viral hepatitis, unspecified 
  B180 Chronic viral hepatitis B with delta-agent 
  B1910 Unspecified viral hepatitis B without hepatic coma
  B1911  Unspecified viral hepatitis B with hepatic coma 
  B1711  Acute hepatitis C with hepatic coma 
  B169 Acute hepatitis B without delta-agent and without hepatic coma 
  B172 Acute hepatitis E
  B182  Chronic viral hepatitis C
  B190 Unspecified viral hepatitis with hepatic coma 
  E1301 Other specified diabetes mellitus with hyperosmolarity with coma 
  E15  Nondiabetic hypoglycemic coma 
  G938  Other specified disorders of brain (terminated 2009-10-01) 
  K750  Abscess of liver
  P914  Neonatal cerebral depression 
  R4020  Unspecified coma 
  R404  Transient alteration of awareness 
  H5500  Unspecified nystagmus 
  H8109  Meniere's disease, unspecified ear 
  H918X9  Other specified hearing loss, unspecified ear 
  H900 Conductive hearing loss, bilateral
  H902  Conductive hearing loss, unspecified 
  H903 Sensorineural hearing loss, bilateral 
  H905  Unspecified sensorineural hearing loss 
  H906  Mixed conductive and sensorineural hearing loss, bilateral 
  F804  Speech and language development delay due to hearing loss 
  H9190  Unspecified hearing loss, unspecified ear 
  Q169  Congenital malformation of ear causing impairment of hearing, unspecified 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

06/01/2019 

Annual review, no change to policy intent. 

06/07/2018 

Annual review, no change to policy intent. 

06/07/2017 

Annual review, no change to policy intent. 

06/16/2016 

Annual review, no change to policy intent. 

03/24/2015 

Interim review. Adding VEMP testing as investigational 

06/30/2015 

Annual review, no change to policy intent. Adding coding. 

06/16/2014

Annual review, no changes  to policy intent.


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