Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Laboratory-Based Vestibular Function Testing

Policy #:07.03.24

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

Laboratory-based vestibular function testing using electronystagmography, videonystagmography, caloric testing, or rotational chair testing for the purpose of a diagnostic evaluation or determining the appropriate medical or surgical treatment is considered medically necessary and, therefore, covered when all of the following conditions have been met:
  • The individual has symptoms of a vestibular disorder (e.g., dizziness, vertigo, imbalance, falls without other medical explanation) and is not clinically diagnosed with benign paroxysmal positional vertigo.
  • Clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has failed to identify the cause of the symptoms.
  • Vestibular rehabilitation or balance retraining, when utilized, has failed to result in an improvement or meet the therapist’s expected performance, as evidenced by documentation of physical performance tests or measurements used to provide objective documentation of a condition or status.

Each of the following Current Procedural Terminology (CPT) codes are covered up to two times per year:
  • 92540 (basic vestibular evaluation)
  • 92541 (spontaneous nystagmus test)
  • 92542 (positional nystagmus test)
  • 92544 (optokinetic nystagmus test)
  • 92545 (oscillating tracking test)
  • 92546 (sinusoidal rotational testing)

Laboratory-based vestibular function testing using vestibular evoked myogenic potential (VEMP) testing for the purpose of a diagnostic evaluation or determining the appropriate medical or surgical treatment is considered medically necessary and, therefore, covered when both of the following conditions have been met:
  • The individual has symptoms that may be suggestive of superior semi-circular canal dehiscence (e.g., noise/sound induced dizziness [Tullio phenomenon], fullness/pressure in the ear, autophony) and is not clinically diagnosed with benign paroxysmal positional vertigo.
  • The individual has had an audiologic evaluation with objective findings suggestive of superior semi-circular canal dehiscence (e.g., air/bone gaps observed during pure tone testing in the presence of normal middle ear function demonstrated by acoustic immittance).

EXPERIMENTAL/INVESTIGATIONAL

All other uses for laboratory-based vestibular function testing are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

All other laboratory-based vestibular function tests not described above are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

NOT MEDICALLY NECESSARY

Laboratory-based vestibular function testing for the assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically (e.g., Dix-Hallpike test, lateral roll test) is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis of illness or injury.

Repeat laboratory-based vestibular function testing when treatment resolves symptoms is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis of illness or injury.

Each of the following CPT codes when performed more than two times per year are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis of illness or injury:
  • 92540 (basic vestibular evaluation)
  • 92541 (spontaneous nystagmus test)
  • 92542 (positional nystagmus test)
  • 92544 (optokinetic nystagmus test)
  • 92545 (oscillating tracking test)
  • 92546 (sinusoidal rotational testing)

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.

For testing performed by a qualified audiologist, the name of the physician ordering the testing must be documented on the audiologist's claim.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, laboratory-based vestibular function testing using electronystagmography and videonystagmography testing batteries, caloric testing, rotational chair testing, or vestibular evoked myogenic potential 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 not medically necessary are not eligible for coverage or reimbursement by the Company.

CLINICAL SPECIALIZATION

Eligible providers performing, supervising, and interpreting vestibular function testing should have knowledge and demonstrated expertise in vestibular function testing. Competency to perform vestibular function testing can be demonstrated through training from a clinical specialization program. This includes professional providers who have completed training requirements sufficient to satisfy relevant American Board of Medical Specialties (ABMS) and American Osteopathic Association (AOA) boards for certification in otolaryngology, neurology, neurologic surgery, and physical medicine and rehabilitation, and audiologists licensed by the state(s) in which they practice and are performing services within their state licensure's scope of practice.

Description

The vestibular system controls balance. It includes five end organs, three semicircular canals sensitive to head rotations, and two otolith organs (saccule, utricle) that sense gravity and straight-line (forward, backward, left, right, downward or upward) accelerations. Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. A number of established laboratory-based vestibular function tests are used to evaluate whether the symptoms are due to dysfunction of the semicircular canals. These tests are based on the vestibulo-ocular reflex, which is an involuntary movement of the eyes (nystagmus) in response to vestibular stimulation. Established laboratory tests include electronystagmography (ENG) and videonystagmography (VNG) test batteries, caloric stimulation, and rotational chair testing. Vestibular evoked myogenic potentials (VEMPs), triggered by sound and vibration, are also being utilized for the diagnosis of otolith dysfunction.

ELECTRONYSTAGMOGRAPHY (ENG) AND VIDEONYSTAGMOGRAPHY (VNG)

The basic electronystagmography (ENG) and videonystagmography (VNG) test batteries include a spontaneous nystagmus test that measures the ability of the eyes to maintain a fixed position, a positional nystagmus test that measures the ability of the eyes to maintain a static position when the head is in different positions, an optokinetic nystagmus test that measures nystagmus caused by viewing a series of targets moving to the right and then to the left, and an oscillating tracking test that evaluates individual ability to track a moving target. ENG uses electrodes at the canthus of the eyes to detect nystagmus while VNG uses infrared video monitoring with goggles to measure nystagmus. The basic ENG/VNG test batteries with these four tests are well established for evaluating vestibular function in individuals who have a suspected vestibular disorder.

CALORIC TESTING

Caloric testing is the most widely used vestibular function test and is considered the criterion standard for detecting unilateral vestibular loss. When warm or cold water or air is introduced into one of the external ear canals, the temperature change is transmitted through the middle ear and bone, causing a thermal gradient in the semicircular canal and resulting in nystagmus. Cold water will cause a movement response of the eye opposite to the stimulation, while warm water will induce nystagmus in the direction of the ear being stimulated. These eye movements can be measured by electrodes at the canthus or by video monitoring. An asymmetrical response after stimulating both ears indicates unilateral vestibular dysfunction.

ROTATIONAL CHAIR TESTING

Rotational chair testing is considered the gold standard for detecting bilateral vestibular loss. Rotational chair devices include a light proof booth, computer driven chair with a head restraint that rotates around a vertical axis, ENG recording, an infrared camera, and a two-way communication system. Typically, the chair is rotated in four different patterns, constant acceleration followed by deceleration, rotating followed by a rapid stop, rotating at progressively increasing velocities, and alternating directions. Each pattern is repeated in both directions several times, and the accompanying post-rotation nystagmus, including parameters of gain, phase, and symmetry, is measured and averaged. Although traditionally used to detect bilateral vestibular loss, this testing can identify a unilateral vestibular deficit and identify the site of the lesion.

VESTIBULAR EVOKED MYOGENIC POTENTIAL TESTING

Vestibular evoked myogenic potential (VEMP) testing uses sound or vibration to stimulate the otolith organs to diagnose otolith dysfunction. Cervical VEMP (cVEMP) measures evoked electrical potentials in the ipsilateral sternocleidomastoid (SCM) muscle following stimulation of the saccule, while ocular VEMP (oVEMP) measures electrical potentials in the extraocular muscles contralateral to the utricle. VEMP testing has been evaluated as a means of assessing superior semicircular canal dehiscence, vestibular neuritis, benign paradoxical positional vertigo (BPPV), vestibular schwannoma, Meniere disease, vestibular migraine, and central vestibular disorders. In a limited application to a subset of individuals, VEMP testing has been reported to be a useful assessment technique to confirm the presence of suspected superior semicircular canal dehiscence syndrome (SSCDS). Dehiscence is rare condition caused by the thinning or absence of the roof of the superior semicircular canal. SSCDS is generally recognized because of various symptoms including aural fullness, pressure induced vertigo, loud noise induced vertigo (Tullio phenomenon), hyperperception of one's own voice, breathing and other internal sounds (autophony), and/or nystagmus. There are several proposed etiologies including the failure of postnatal bone development resulting in thin roofs of the superior canals, thin bone worn down by age, and trauma. Occasionally the bone over the superior canal is removed surgically, which can create a dehiscence. Individuals with SSCDS have reduced thresholds for VEMP response in the affected ear for both air and bone conduction as well as larger VEMP amplitides with 80 percent sensitivity and specificity. VEMP testing has not been validated for diagnoses other than SSCDS.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign paroxysmal positional vertigo (BPPV) with a typical presentation is usually diagnosed clinically with a combination of a history of periods of brief positional vertigo, recurrence of symptoms with the Dix-Hallpike maneuver or lateral roll procedures, and/or alleviation of symptoms after canal repositioning maneuver. The Dix-Hallpike maneuver is the criterion standard for the diagnosis of posterior canal BPPV, limiting evaluation of its performance characteristics. The 2008 practice guidelines from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) gave a strong recommendation for the diagnosis of BPPV of the posterior canal when vertigo associated with nystagmus has been provoked by the Dix-Hallpike maneuver. If the Dix-Hallpike maneuver is negative, but the history is consistent with BPPV, a lateral roll test can be used to assess BPPV of the horizontal canal. In the event that both the Dix-Hallpike maneuver and lateral roll tests are negative, alleviation of symptoms with the canal repositioning maneuver supports a diagnosis of BPPV. AAO-HNS has recommended against vestibular function testing in individuals who meet clinical criteria for the diagnosis of BPPV. Thus, laboratory-based vestibular function testing do not add diagnostic information in such routine cases. The evidence is sufficient to determine that the technology is unlikely to improve net health outcome. If the clinical presentation is atypical, if Dix-Hallpike testing elicits equivocal or unusual nystagmus findings, if symptoms do not resolve following treatment, or if there are additional symptoms or signs, laboratory-based vestibular function testing may be indicated.
References


American Academy of Audiology. Position statement on the audiologist's role in the diagnosis and treatment of vestibular disorders. 2018. Available at: http://www.audiology.org/publications-resources/document-library/position-statement-audiologists-role-diagnosis-treatment. Accessed July 31, 2018.

American Academy of Audiology. Scope of practice. Audiol Today. 2004;15(3):44-45.

Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 Suppl 4):S47-81.

Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (Update). Otolaryngol Head Neck Surg.2017;156(3_suppl):S1-S47.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub. 100-02: Medicare Claims Processing. Transmittal 84. [CMS Web site]. 04/01/2008. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R84BP.pdf. Accessed July 31, 2018.

Colebatch JG, Rosengren SM, Welgampola MS. Vestibular-evoked myogenic potentials. Handb Clin Neurol. 2016;137:133-155.

Ertl M, Boegle R, Kirsch V, et al. On the impact of examiners on latencies and amplitudes in cervical and ocular vestibular-evoked myogenic potentials evaluated over a large sample (N = 1,038). Eur Arch Otorhinolaryngol. 2016;273(2):317-323.

Fife TD, Colebatch JG, Kerber KA, et al. Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology2017;89(22):2288-2296.

Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and children: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000;55(10):1431-1441.

Furman JM, Barton JJ. Evaluation of the patient with vertigo. [UpToDate Web site]. 6/10/2015. Available at: https://www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo?source=search_result&search=VEMP&selectedTitle=1~3 [via subscription only]. Accessed July 31, 2018.

Gofrit SG, Mayler Y, Eliashar R, et al. The association between vestibular physical examination, vertigo questionnaires, and the electronystagmography in patients with vestibular symptoms. Ann Otol Rhinol Laryngol. 2017;126(4):315-321.

Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14(3):201-204.

Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: From the American Physical Therapy Association Neurology Section. J Neurol Phys Ther. 2016;40(2):124-155.

Halmagyi GM, Curthoys IS. Otolith function tests. In: Herdman SJ, Clendaniel RA, eds. Vestibular Rehabilitation. Vol Contemporary Perspectives in Rehabilitation: F.A. Davis; 2014:195-225.

Hunter JB, Patel NS, O'Connell BP, et al. Cervical and ocular VEMP testing in diagnosing superior semicircular canal dehiscence. Otolaryngol Head Neck Surg. 2017;156(5):917-923.

Konopka W, Mielczarek M, Michalski M, et al. Hearing evaluation in patients with vertigo. Otolaryngol Pol. 2006;60(2):239-241.

Li JC. Benign Paroxysmal Positional Vertigo Treatment & Management. [Medscape web site]. 02/15/2018. Available at: http://emedicine.medscape.com/article/884261-treatment. Accessed July 31, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35007: Vestibular and audiologic function studies. [Novitas Solutions, Inc. Web site]. 12/14/2017. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35007&ver=66&name=331*1&UpdatePeriod=759&bc=AAAAEAAAAAAAAA%3d%3d&. Accessed July 31, 2018.

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. 2014;125(4):658-666.

Schubert MC. Vestibular function tests. In: Herdman SJ, Clendaniel RA, eds. Vestibular Rehabilitation. Vol Contemporary Perspectives in Rehabilitation: F.A. Davis; 2014:178-194.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. ICS Chartr EP 200 with VEMP. [FDA Web site]. 10/23/2015. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf14/k143670.pdf. Accessed July 31, 2018.

Vestibular Disorders Association (VEDA). Diagnostic tests for vestibular problems. [VDA Web site]. 2015. Available at:
http://vestibular.org/sites/default/files/page_files/Documents/Diagnostic%20Tests%20for%20Vestibular%20Disorders.pdf. Accessed July 31, 2018.

Vestibular Disorders Association (VEDA). Superior Semicircular Canal Dehiscence (SSCD). [VDA Web site]. Available at: http://vestibular.org/superior-canal-dehiscence-scd. Accessed July 31, 2018.

Weber KP, Rosengren SM. Clinical utility of ocular vestibular-evoked myogenic potentials (oVEMPs). Curr Neurol Neurosci Rep. 2015;15(5):22.

Welgampola MS, Colebatch JG. Vestibulocollic reflexes: normal values and the effect of age. Clin Neurophysiol. 2001;112(11):1971-1979.

Yew A, Zarinkhou G, Spasic M, et al. Characteristics and management of superior semicircular canal dehiscence. J Neurol Surg B Skull Base.2012;73(6):365–370.

Zhou G, Gopen Q, Poe DS. Clinical and diagnostic characterization of canal dehiscence syndrome: A great otologic mimicker. Otology & Neurotology.2007;28(7):920-926.

Zuniga MG, Janky KL, Nguyen KD, et al. Ocular vs. cervical VEMPs in the diagnosis of superior semicircular canal dehiscence syndrome.Otol Neurotol. 2013;34(1):121–126.





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)

92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547


THE FOLLOWING CODE IS USED TO REPRESENT VESTIBULAR EVOKED MYOGENIC POTENTIAL TESTS

92700



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)

A88.1 Epidemic vertigo

H81.01 Meniere's disease, right ear

H81.02 Meniere's disease, left ear

H81.03 Meniere's disease, bilateral

H81.09 Meniere's disease, unspecified ear

H81.10 Benign paroxysmal vertigo, unspecified ear

H81.11 Benign paroxysmal vertigo, right ear

H81.12 Benign paroxysmal vertigo, left ear

H81.13 Benign paroxysmal vertigo, bilateral

H81.20 Vestibular neuronitis, unspecified ear

H81.21 Vestibular neuronitis, right ear

H81.22 Vestibular neuronitis, left ear

H81.23 Vestibular neuronitis, bilateral

H81.311 Aural vertigo, right ear

H81.312 Aural vertigo, left ear

H81.313 Aural vertigo, bilateral

H81.319 Aural vertigo, unspecified ear

H81.391 Other peripheral vertigo, right ear

H81.392 Other peripheral vertigo, left ear

H81.393 Other peripheral vertigo, bilateral

H81.399 Other peripheral vertigo, unspecified ear

H81.41 Vertigo of central origin, right ear

H81.42 Vertigo of central origin, left ear

H81.43 Vertigo of central origin, bilateral

H81.49 Vertigo of central origin, unspecified ear

H81.8X1 Other disorders of vestibular function, right ear

H81.8X2 Other disorders of vestibular function, left ear

H81.8X3 Other disorders of vestibular function, bilateral

H81.8X9 Other disorders of vestibular function, unspecified ear

H81.90 Unspecified disorder of vestibular function, unspecified ear

H81.91 Unspecified disorder of vestibular function, right ear

H81.92 Unspecified disorder of vestibular function, left ear

H81.93 Unspecified disorder of vestibular function, bilateral

H82.1 Vertiginous syndromes in diseases classified elsewhere, right ear

H82.2 Vertiginous syndromes in diseases classified elsewhere, left ear

H82.3 Vertiginous syndromes in diseases classified elsewhere, bilateral

H82.9 Vertiginous syndromes in diseases classified elsewhere, unspecified ear

H83.01 Labyrinthitis, right ear

H83.02 Labyrinthitis, left ear

H83.03 Labyrinthitis, bilateral

H83.09 Labyrinthitis, unspecified ear

H83.11 Labyrinthine fistula, right ear

H83.12 Labyrinthine fistula, left ear

H83.13 Labyrinthine fistula, bilateral

H83.19 Labyrinthine fistula, unspecified ear

H83.2X1 Labyrinthine dysfunction, right ear

H83.2X2 Labyrinthine dysfunction, left ear

H83.2X3 Labyrinthine dysfunction, bilateral

H83.2X9 Labyrinthine dysfunction, unspecified ear

H83.8X1 Other specified diseases of right inner ear

H83.8X2 Other specified diseases of left inner ear

H83.8X3 Other specified diseases of inner ear, bilateral

H83.8X9 Other specified diseases of inner ear, unspecified ear

H83.90 Unspecified disease of inner ear, unspecified ear

H83.91 Unspecified disease of right inner ear

H83.92 Unspecified disease of left inner ear

H83.93 Unspecified disease of inner ear, bilateral

H90.0 Conductive hearing loss, bilateral

H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

H90.2 Conductive hearing loss, unspecified

H90.3 Sensorineural hearing loss, bilateral

H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

H90.5 Unspecified sensorineural hearing loss

H90.6 Mixed conductive and sensorineural hearing loss, bilateral

H90.71 Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.72 Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

H90.8 Mixed conductive and sensorineural hearing loss, unspecified

H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side

H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side

H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side

H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side

H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side

H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side

H91.01 Ototoxic hearing loss, right ear

H91.02 Ototoxic hearing loss, left ear

H91.03 Ototoxic hearing loss, bilateral

H91.09 Ototoxic hearing loss, unspecified ear

H91.10 Presbycusis, unspecified ear

H91.11 Presbycusis, right ear

H91.12 Presbycusis, left ear

H91.13 Presbycusis, bilateral

H91.20 Sudden idiopathic hearing loss, unspecified ear

H91.21 Sudden idiopathic hearing loss, right ear

H91.22 Sudden idiopathic hearing loss, left ear

H91.23 Sudden idiopathic hearing loss, bilateral

H91.8X1 Other specified hearing loss, right ear

H91.8X2 Other specified hearing loss, left ear

H91.8X3 Other specified hearing loss, bilateral

H91.8X9 Other specified hearing loss, unspecified ear

H91.90 Unspecified hearing loss, unspecified ear

H91.91 Unspecified hearing loss, right ear

H91.92 Unspecified hearing loss, left ear

H91.93 Unspecified hearing loss, bilateral

R42 Dizziness and giddiness



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

07.03.24
09/26/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on laboratory-based vestibular function testing.
02/13/2018This version of the policy will become effective 02/13/2018.

The following new policy has been developed to communicate the Company’s coverage criteria for laboratory-based vestibular function testing.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 02/13/2018
Version Issued Date: 02/13/2018
Version Reissued Date: 09/26/2018

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