Brainstem auditory evoked potentials (BAEPs) for evaluation of individuals with vertigo.Balance Tracking System (BTrackS) for evaluation of risk of falling.Balanceback Intuitive VNG device for the management of balance disorders.The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established (not an all-inclusive list): VNG as a medically necessary alternative to ENG for assessment of vestibular disorders.ĮNG and VNG are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.ENG for evaluation of persons with symptoms of vestibular disorders (dizziness, vertigo, disequilibrium or imbalance).Electronystagmography (ENG) and Videonystagmography (VNG).See also CPB 0181 - Evoked Potential Studies. Ocular and cervical vestibular evoked myogenic potentials (cVEMP and oVEMP) to evaluate persons with vertigo for superior semicircular canal dehiscence syndrome (SCDS) who have had a comprehensive evaluation (history, physical, audiometry, electro- or videonystagmography, electrocochleography, brainstem audiometry) and the results are inconclusive. If there is no evidence of improvement after 12 visits, additional visits are not considered medically necessary. Up to 12 additional visits are considered medically necessary if, upon medical review, there is evidence of clinically significant improvement. Note: Up to 12 visits (generally given 2 times a week for 6 weeks) are considered medically necessary initially. Vestibular rehabilitation is considered experimental and investigational for all other indications because its effectiveness for indications other than the one listed above has not been established. The member has failed medical management (e.g., use of vestibular suppressant medications to reduce symptoms).The member has confirmed diagnosis of a vestibular disorder or has undergone ablative vestibular surgery and.Symptoms (e.g., vertigo and imbalance) have existed for more than 6 months and.For individuals with these diagnoses and all other indications, use of the Epley maneuver or the Semont maneuver is considered experimental and investigational.įor chronic vertigo / persistent postural perceptual dizziness (PPPD) when all of the following criteria are met: The Epley maneuver and the Semont maneuver have not been demonstrated to be effective in persons with disorders of the central nervous system such as temporal lobe epilepsy, multiple sclerosis, cerebrovascular disease, vertiginous migraine, cerebellopontine angle tumors, and primary or metastatic cerebellar lesions, based on neurological examination, magnetic resonance imaging, or history. Member had symptoms of BPPV for at least 4 months.Diagnosis of BPPV has been confirmed by a positive Hallpike test, and.Use of the Epley maneuver (also known as canalith repositioning procedure) or the Semont maneuver for the treatment of BPPV when both of the following selection criteria are satisfied:.Positional nystagmus test (Barany or Dix-Hallpike maneuver) for the diagnosis of BPPV.Maneuvers for Benign Paroxysmal Positioning Vertigo (BPPV).Vibration induced nystagmus testing (VIN), skull vibration induced nystagmus testing (SVINT), bone conduction vibration.Diagnosis and Evaluation of Chronic Vertigo or Ménière's Disease.This Clinical Policy Bulletin addresses chronic vertigo.Īetna considers the following procedures as medically necessary (unless otherwise specified) for chronic vertigo: Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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