Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Smell and Taste Dysfunction Testing

Policy #:07.11.01c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Smell/olfactory and/or taste dysfunction testing is considered medically necessary and, therefore, covered when ordered by a professional provider to rule out an underlying medical condition requiring treatment when either one, or both, of the following medical necessity criteria are met:
  • There is an unexplained decrease or distortion in the sense of smell (anosmia, hyposmia, dysosmia).
  • There is a loss of taste (ageusia, hypogeusia, dysgeusia) associated with a severe loss in the sense of smell.

A total of five of the following tests (a combination of codes 92700 and 41599) are eligible for reimbursement. Additional testing is considered not medically necessary and, therefore, not covered.

The following tests may be performed to evaluate smell/taste dysfunction:
  • Odor identification testing (92700), for example:
    • 40-odorant University of Pennsylvania Smell Identification Test (UPSIT)
    • 12-odor Brief-Smell Identification Test (B-SIT)
    • 3-odor Pocket Smell Test (PST) (Sensonics, Inc., Haddon Heights, NJ)
  • Whole-mouth taste suprathreshold testing (41599)
  • Smell threshold (detection) testing (92700)
  • Smell suprathreshold testing (92700)
  • Smell unilateral testing (92700)
  • Taste quadrant (regional) testing (41599)
  • Taste-suprathreshold testing (41599)

EXPERIMENTAL/INVESTIGATIONAL

A number of diagnostic tests are considered experimental/investigational and, therefore, not covered when used in the diagnosis of smell/taste disorders including, but not limited to:
  • Biopsy of the olfactory epithelium
  • Electrogustometry
  • Acoustic rhinometry
  • Rhinomanometry
  • Single-photon emission computed tomography (SPECT)
  • Positron emission tomography (PET)
  • Functional magnetic resonance imaging (fMRI)

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, smell and taste dysfunction testing is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational and not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

SMELL/OLFACTORY DYSFUNCTION

Loss of, or injury to, the sense of smell (also known as olfactory dysfunction) is common in the general population and can significantly affect an individual's quality of life, nutrition, and safety. The terms hyposmia, dysosmia, and anosmia refer to diminished, altered, and total loss of smell, respectively. Dysosmia is further divided into parosmia (altered perception of an odor with a stimulus present) and phantosmia (perception of an odor in the absence of a stimulus). Possible causes of smell/olfactory dysfunction include viral infections, head trauma, nasal polyps, aging, environmental toxins, drugs, radiation therapy, congenital defects, and endocrine, autoimmune, neurologic, and psychiatric disorders. Approximately 25 percent of smell-loss cases are related to respiratory infection.

Quantitative assessment of smell function is important for validating an individual's condition, characterizing the nature of the problem, and objectively monitoring the results of treatment. Smell/olfactory dysfunction is primarily assessed in a clinic through one or more psychophysical tests. These specific standardized tests are performed following the completion of a standard history and physical examination. The most widely used tests are classified as either odor identification tests (which assess the individual's ability to identify a number of odors) or smell threshold tests (which determine the lowest concentration of an odorant that can be reliably detected).

In summary, odor identification testing, smell threshold testing, smell suprathreshold testing, and smell unilateral testing are widely accepted psychophysical tests to evaluate smell/olfactory dysfunction. Their benefit to an individual's net health outcome is equal or superior to any established alternatives.

ODOR IDENTIFICATION TESTS

Smell testing by means of a standardized odor identification test or smell/olfactory threshold test with established reliability, sensitivity, and validity is now widely accepted. Studies on a number of these tests have established test-retest reliability, normative values in relation to different age groups, and validity in comparison to established measures of smell sensitivity such as the University of Connecticut Test Battery. The University of Connecticut Test Battery is a commonly used test with both smell threshold and odor identification components. During the smell threshold component, the individual is evaluated based on their ability to detect increasing concentrations of butanol-containing solutions in a series of paired bottles. During the odor identification component, the individual's ability to identify eight different odors is assessed. Each nostril is tested separately. Results are then combined with the threshold test to provide a composite score.

Another commonly used odor identification test is the 40-odorant University of Pennsylvania Smell Identification Test (UPSIT), known commercially as the Smell Identification Test (SIT). UPSIT (which contains both odor identification and smell threshold testing components) is widely used. This test is highly reliable, employs norms based on nearly 4,000 persons, and is available in several languages. During the UPSIT, the individual scratches off a microencapsulated label with a pencil tip, smells the label, and selects the odor quality from four alternatives. Even if no smell is perceived, a response is required (ie, the test is forced-choice). In addition to indicating the level of absolute smell function (ie, normosmia, mild hyposmia, moderate hyposmia, severe hyposmia, total anosmia), the UPSIT provides a percentile rank for each age and gender group. Malingering is detected on the basis of improbable responses.

The 12-odor Brief-Smell Identification Test (B-SIT), also known as the Cross-Cultural Smell Identification Test, is comprised of selected UPSIT items that are most familiar to people from North American, European, South American, and Asian cultures. This test measures smell/olfactory function in the clinical setting when time is limited. The disadvantage of this test is that its brevity limits its sensitivity to subtle changes in smell/olfactory function.

The 3-odor Pocket Smell Test (PST) provides a very brief screen of gross smell dysfunction. If the individual misses one or more of the three items on the test, the 40-odorant UPSIT should be administered to more accurately quantify the degree of smell loss.

Odor identification tests are more reliable than smell threshold tests and require less administration time. In addition, most odor identification tests can be self-administered and tend to correlate better with an individual's condition. Nonetheless, odor identification and smell threshold tests are typically correlated.

SMELL THRESHOLD TESTS AND SMELL SUPRATHRESHOLD TESTS

The second step in assessing smell dysfunction typically involves smell threshold testing. During this test, odorants are presented in a liquid diluent, such as odorless mineral oil, in small containers and held over the nose. Smell threshold tests are used to determine the lowest concentration of an odorant that an individual can reliably detect. The commercially available smell threshold test (the STT [Sensonics, Inc., Haddon Heights, NJ]) uses a single-staircase (SS) methodology to maintain reliability. The kit provides squeeze bottles containing various half-log step concentrations of an odorant known to primarily stimulate the nerve associated with smell. One common odorant used is the rose-like smelling phenyl ethyl alcohol (PEA). Test result patterns have been established based on hundreds of subjects spanning the entire age range, and the test is used widely in medical and industrial settings.

Current practice in smell threshold testing requires the subject to choose which of two or more stimuli (ie, an odorant and one or more blanks) smells strongest, rather than to just report whether an odorant is perceived. Such forced-choice procedures are less affected by biases than non-forced-choice procedures.

Threshold levels obtained during smell threshold testing typically agree with the results obtained from odor identification testing. Although some individuals fail odor identification testing but perform normally on smell threshold testing, the reverse is rare. In practice, the results of the identification testing are weighted more heavily in arriving at a diagnosis due to the fact that some individuals use subtle noncranial nerve cues to obtain low detection thresholds. This judgment must be applied with care, however, because odor identification testing can be sensitive to conditions that cause distortions of smell function that are not accompanied by changes in the detection threshold, including some forms of agnosia. Although such conditions are rare compared with conditions such as viral illness and nasal obstruction, they should be considered when central nervous system damage is known or suspected.

SMELL UNILATERAL TESTING

Unilateral testing following a comprehensive test such as UPSIT may be necessary in some clinical situations. This is done by performing odor identification and smell threshold testing while one nostril is occluded. However, the majority of smell disorders are bilateral.

TASTE DYSFUNCTION

Taste dysfunction often accompanies severe smell dysfunction. However, there are also taste disorders that are not associated with smell dysfunction, such as those that occur with injury to the chorda tympani nerve during dental procedures or inner ear infections. Therefore, taste testing is appropriate in a comprehensive evaluation of smell dysfunction.

WHOLE-MOUTH TASTE TESTING, TASTE THRESHOLD (DETECTION) TESTING, TASTE QUADRANT (REGIONAL) TESTING, AND THE CATEGORY OF TASTE SUPRATHRESHOLD TESTING

Numerous procedures have been developed for evaluating taste function. The current mainstays include whole-mouth taste testing, taste threshold (detection) testing, and taste quadrant (regional) testing. The term taste-suprathreshold testing can be confusing because it denotes a category of taste tests, which includes the whole-mouth taste test, the taste threshold test, and the taste quadrant (regional) test. These tests each employ various concentrations of sweet, sour, bitter, and salty stimuli to establish suprathreshold components of taste dysfunction.

The reliability between quadrant (regional) and suprathreshold test/retests (which may be given daily, weekly, or monthly) generally varies. This is partly due to the fact that each testing center makes up its own testing solutions on an as-needed basis. In addition, reliability varies among tasters. As a result, reliability assessment is almost never done. However, during taste testing, the individual serves as their own control. Despite the above limitations, these tests are widely used and provide significant benefit in identifying and qualifying taste disorders. For example, by the late 1980s, the taste quadrant (regional) test was proven a reliable method for identifying discrete taste loss caused by head trauma, upper respiratory infection, bulimia, and aging. In addition, a 1995 study by Matsuda and Doty reported that out of a series of 12 elderly individuals, none were able to detect NaCl (salt) presented to small regions of the tongue, compared with 12 younger individuals with no such deficit.

Although scientific evidence supporting the reliability and validity of the whole-mouth taste test, the taste threshold test, and the taste quadrant (regional) test in the diagnosis of smell disorders is limited, the consensus among leading authorities is that these tests provide benefit and contribute significantly to medical outcomes.

ELECTROGUSTOMETRY

Electrogustometry can be used to identify a gross neural deficit. However, its use in the clinic is limited by the fact that it cannot elicit all taste qualities reliably. For example, when direct current is used during testing, a sour taste is typically evoked if the anode is applied to the tongue. Reversing the current brings about a less distinct response described as soap-like, metallic, or bitter. Sweet sensations are rarely, if ever, elicited using an electrical stimulus.

In general, the safety and efficacy of using electrogustometry on the clinical population cannot be established based on the review of available published literature. Furthermore, opinions and evaluations by national medical associations, consensus panels, and other technology evaluation bodies regarding the routine use of electrogustometry are lacking.

SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT), POSITRON EMISSION TOMOGRAPHY (PET), FUNCTIONAL MAGNETIC RESONANCE IMAGING (fMRI), ACOUSTIC RHINOMETRY, AND RHINOMANOMETRY

A number of other tests with limited scientific evidence to support their usefulness are being investigated for their value in evaluation of smell and taste disorders. These tests include:
  • Single-photon emission computed tomography (SPECT)
  • Positron emission tomography (PET)
  • Functional magnetic resonance imaging (fMRI)
  • Acoustic rhinometry
  • Rhinomanometry

SPECT and PET are physiological imaging techniques used in research to assess changes in cerebral blood during sensory challenges, as occurs during smelling.

fMRI is a relatively new procedure that uses MR imaging to measure the quick, tiny metabolic changes that take place in an active part of the brain.

Acoustic rhinometry is a procedure that uses sound waves to assess the geometry of the nasal cavity and nasopharynx and thus nasal obstruction. Rhinomanometry uses air pressure and rate of flow to measure nasal airway resistance and patency. Acoustic rhinometry and rhinomanometry are proposed for the assessment of individuals prior to nasal surgery, and in the assessment of the decongestive action of antihistamines and corticosteroids.

There is insufficient scientific evidence to support the use of SPECT, PET, fMRI, acoustic rhinometry, or rhinomanometry in the diagnosis of smell disorders. Furthermore, opinions and evaluations by national medical associations, consensus panels, and other technology evaluation bodies regarding their routine use are lacking.

BIOPSY OF THE OLFACTORY EPITHELIUM

Olfactory epithelium biopsies have been used to evaluate individuals with smell dysfunction. However, larger studies with individuals who have different causes of an impaired sense of smell are needed to determine specific changes in the epithelium. Therefore, at this time there is insufficient evidence in the available published medical literature to support the use of biopsy of the olfactory epithelium in the diagnosis of smell disorders.

NASAL ENDOSCOPY

The use of nasal endoscopy in individuals with suspected nasal or sinus disease is an accepted standard practice.

ELECTROENCEPHALOGRAPHY

The use of electroencephalography to evaluate individuals whose history suggests a seizure disorder is an accepted standard practice.

STANDARD CLINICAL TRIGEMINAL NERVE IMAGING AND OTHER TESTING

In addition to olfactory nerve testing, evaluation of smell loss may include testing of the trigeminal nerve, which is involved in the detection of pain, pressure, and temperature sensations in the mouth, nasal cavity, and eyes. Assessment of trigeminal nerve function is accomplished by testing the individual's ability to detect pungent odors, such as capsaicin (the hot component to hot chili powder and mace spray), mustard oil, and onion.

OTHER TESTS USED TO ASSESS SMELL/OLFACTORY DYSFUNCTION

In addition to a standard history, physical examination, and psychophysical testing for assessment of smell/olfactory dysfunction, the following laboratory studies may be required:
  • Hematocrit
  • Hemoglobin
  • Red cell indices
  • White cell count
  • Blood glucose and urea nitrogen
  • Serum calcium, bilirubin, and creatinine
  • Liver enzymes
  • Prothrombin time
  • Eosinophil count
  • Thyroid function studies
  • Serologic test for syphilis
  • Angiotensin-converting enzyme
  • Immunoglobulin E

Additionally, there are a number of other psychophysical methods for evaluating smell/olfactory dysfunction such as magnitude estimation and multidimensional scaling. However, compared to accepted smell tests, these have not been shown to contribute substantial clinical information.
References


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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODE IS USED TO REPRESENT SMELL/OLFACTORY DYSFUNCTION TESTING (EG, THE UNIVERSITY OF PENNSYLVANIA SMELL IDENTIFICATION TEST [UPSIT], SMELL IDENTIFICATION TEST [SIT], BRIEF-SMELL IDENTIFICATION TEST [B-SIT], 3-ODOR POCKET SMELL TEST [PST], SMELL THRESHOLD TEST, SMELL SUPRATHRESHOLD TEST, AND/OR SMELL UNILATERAL TESTING):

92700


THE FOLLOWING CODE IS USED TO REPRESENT TASTE DYSFUNCTION TESTING (EG, WHOLE-MOUTH TASTE TEST, TASTE THRESHOLD TEST, TASTE QUADRANT [REGIONAL] TEST, TASTE SUPRATHRESHOLD TESTING):

41599


EXPERIMENTAL/INVESTIGATIONAL:

THE FOLLOWING CODE IS USED TO REPRESENT ELECTROGUSTOMETRY:

41599

THE FOLLOWING SERVICES ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL WHEN USED FOR THE DIAGNOSIS OF SMELL/TASTE DISORDERS

30100, 92512


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

G52.0 Disorders of olfactory nerve

R43.0 Anosmia

R43.1 Parosmia

R43.2 Parageusia

R43.8 Other disturbances of smell and taste

R43.9 Unspecified disturbances of smell and taste



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 07.11.01c:
05/07/2018This version of the policy will become effective 05/07/2018. The intent of this policy remains unchanged.


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.