Clinical UM Guideline
|Subject:||Visual, Somatosensory and Motor Evoked Potentials|
|Guideline #:||CG-MED-50||Current Effective Date:||07/07/2015|
|Status:||Reviewed||Last Review Date:||05/07/2015|
This document addresses non-operative uses of the following evoked potential (EP) studies:
Evoked potentials (EPs) or evoked responses are electrical waves created in the central nervous system by peripheral stimulation of a sensory organ. EPs are used to identify abnormal central nervous system function that may not be detected clinically.
Note: This document does not address intra-operative uses for VEPs, SSEPs, or MEPs.
I. Visual Evoked Potentials:
Visual evoked potentials (VEPs) are considered medically necessary for the diagnosis, evaluation, or monitoring of any of the following conditions:
Not Medically Necessary:
Visual evoked potentials (VEPs) are considered not medically necessary for all other uses, including but not limited to routine screening of infants.
II. Somatosensory evoked potentials (SSEPs):
Somatosensory evoked potentials (SSEPs) are considered medically necessary when the results will be used to guide clinical management for the following conditions:
Not Medically Necessary:
Somatosensory evoked potentials (SSEPs) are considered not medically necessary for all other uses.
III. Motor evoked potential testing:
Motor evoked potentials are considered medically necessary for evaluation of suspected hysterical or factitious paralysis.
Not Medically Necessary:
Motor evoked potentials are considered not medically necessary in the non-operative setting when the above criteria are not met.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|0333T||Visual evoked potential, screening of visual acuity, automated|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs|
|95927||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95929||Central motor evoked potential study (transcranial motor stimulation); lower limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95938||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs|
|95939||Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|300.10-300.19||Dissociative, conversion and factitious disorders [hysterical or factitious paralysis]|
|333.0||Other degenerative diseases of the basal ganglia|
|336.9||Unspecified disease of spinal cord (myelopathy NOS)|
|341.0-341.9||Other demyelinating diseases of central nervous system|
|348.1||Anoxic brain damage|
|369.00-369.9||Blindness and low vision|
|377.00-377.54||Disorders of the optic nerve|
|377.9||Unspecified disorder of optic nerve and visual pathways|
|768.70-768.73||Hypoxic-ischemic encephalopathy [HIE]|
|768.9||Unspecified birth asphyxia in liveborn infant|
|854.00-854.19||Intracranial injury of other and unspecified nature|
|952.01||Spinal cord injury without evidence of spinal bone injury, C1-C4 level with complete lesion of spinal cord|
|952.04||Spinal cord injury without evidence of spinal bone injury, C1-C4 level with other specified spinal cord injury|
|952.06||Spinal cord injury without evidence of spinal bone injury, C5-C7 level with complete lesion of spinal cord|
|952.09||Spinal cord injury without evidence of spinal bone injury, C5-C7 level with other specified spinal cord injury|
|952.11||Spinal cord injury without evidence of spinal bone injury, T1-T6 level with complete lesion of spinal cord|
|952.14||Spinal cord injury without evidence of spinal bone injury, T1-T6 level with other specified spinal cord injury|
|951.16||Spinal cord injury without evidence of spinal bone injury, T7-T12 level with complete lesion of spinal cord|
|952.19||Spinal cord injury without evidence of spinal bone injury, T7-T12 level with other specified spinal cord injury|
|952.2||Spinal cord injury without evidence of spinal bone injury, lumbar|
|952.3||Spinal cord injury without evidence of spinal bone injury, sacral|
|997.01||Central nervous system complication (anoxic brain damage)|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|F44.4||Conversion disorder with motor symptom or deficit [hysterical paralysis]|
|G23.0-G23.9||Other degenerative diseases of basal ganglia|
|G36.0-36.9||Other acute disseminated demyelination|
|G37.0-G37.9||Other demyelinating disease of central nervous system|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G95.9||Disease of spinal cord, unspecified (myelopathy NOS)|
|G97.81-G97.82||Other intraoperative and postprocedural complications and disorders of nervous system|
|H47.011-H47.49||Disorders of optic nerve, not elsewhere classified|
|H54.0-H54.8||Blindness and low vision|
|P84||Other problems with newborn (asphyxia of newborn NOS)|
|P91.60-P91.63||Hypoxic ischemic encephalopathy [HIE]|
|S06.1X6A-S06.9X6S||Intracranial injury (with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving [code range with 6th character 6 and 7th character A-S]|
|S14.111A-S14.119S||Complete lesion of cervical spinal cord|
|S14.141A-S14.149S||Brown-Sequard syndrome of cervical spinal cord|
|S14.151A-S14.159S||Other incomplete lesions of cervical spinal cord|
|S24.111A-S24.119S||Complete lesion of thoracic spinal cord|
|S24.141A-S24.149S||Brown-Sequard syndrome of thoracic spinal cord|
|S24.151A-S24.159S||Other incomplete lesions of thoracic spinal cord|
|S34.111A-S34.119S||Complete lesion of lumbar spinal cord|
|S34.121A-S34.129S||Incomplete lesion of lumbar spinal cord|
|S34.131A-S34.139S||Other and unspecified injury to sacral spinal cord|
|S34.3XXA-S34.3XXS||Injury of cauda equina|
EPs are recordings of the nervous system's electrical response to the stimulation of specific sensory pathways. These recordings have the ability to provide information relative to the functional integrity of pathways within the nervous system. Only a few EPs are used on a routine basis and those most frequently encountered include VEPs and SSEPs.
Visual Evoked Potentials (VEPs)
VEPs track signals from the retina to the visual cortex and determine how a visual system reacts to light. A common indication for VEPs is to help confirm the diagnosis of MS, or to evaluate and monitor MS. In general, myelin plaques which occur in MS slow the speed of VEP wave peaks. Over time VEPs in individuals with MS become progressively slower eventually attenuating in amplitude as demyelination increases (Creel, 2012). The American Academy of Neurology (AAN) (Gronseth, 2000) recommends VEPs as probably useful to identify those at increased risk for clinically definite MS.
VEPs have also been used for other conditions including neuromyelitis optica (NMO) or other demyelinating disorders of the optic nerves, or for a suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by magnetic resonance imaging (MRI), computerized tomography (CT), infectious diseases or metabolic disorders.
The U.S. Preventive Services Task Force (USPSTF) (2011) has not recommended vision screening for infants and young children. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children less than 3 years of age.
van Laerhoven and colleagues (2013) performed a systematic literature review to investigate the prognostic value of current clinical tests used for evaluation of long-term neurodevelopmental outcome of neonates with perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE). A total of 29 studies were included in the review describing 13 prognostic tests performed 1631 times in 1306 term neonates. A considerable heterogeneity was noted in test performance, cut-off values, and outcome measures. The VEP (sensitivity 0.90 [0.74-0.97]; specificity 0.92 [0.68-0.98]) was found to be one of the most promising tests. The authors concluded that although the prognostic value of the test is promising, investigation in well-designed prospective studies is needed before standardized clinical use is advocated.
Somatosensory Evoked Potentials (SSEPs)
SSEPs are electrical waves that are generated by the response of sensory neurons to stimulation. An abnormal SSEP finding demonstrates that there is dysfunction within the somatosensory pathways.
SSEP studies may be useful for helping to assess the extent of injury and predict outcomes in persons with traumatic, hypoxic-ischemic and other diffuse brain injuries, who are comatose. Rothstein (2009) studied 50 comatose individuals with preserved brainstem function after cardiac arrest. A total of 23 of the 50 had bilateral absence of cortical EPs and all died without awakening. Neuropathological study in seven of those that died displayed widespread ischemic changes or frank cortical laminar necrosis. The remaining 27 had normal or delayed central conduction times with some dying without awakening or entering a persistent vegetative state. The majority of individuals with normal central conduction times had good outcomes, whereas a delay in central conduction times increased the likelihood of neurologic deficit or death. It was noted that greater use of SSEPs in anoxic-ischemic coma and severe brain trauma would identify those persons unlikely to recover.
Wijdicks and colleagues (2006) for the Quality Standards Subcommittee of the American Academy of Neurology issued a practice parameter on "Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review)". The authors recommended that the assessment of poor prognosis can be guided by the bilateral absence of cortical SSEPs (N20 response) within 1 to 3 days (recommendation level B).
The American Academy of Neurology (AAN) (Gronseth, 2000) recommends SSEPs as possibly useful to identify those at increased risk of for developing clinically definite MS.
Additional indications for SSEPs include: acute anoxic encephalopathy; deficit of the central nervous system identified on exam, but not explained by appropriate imaging studies; demyelinating diseases under certain conditions; unexplained myelopathy; spinocerebral degeneration (such as Friedreich's ataxia); spinal cord lesions secondary to trauma when the need for surgical intervention is uncertain; or suspected brain death.
Motor Evoked Potentials (MEPs)
MEPs evaluate motor pathways located in the anterolateral spinal tracts perfused by the anterior spinal artery. Single- or repetitive-pulse stimulation of the brain causes the spinal cord and peripheral muscles to produce neuroelectrical signals known as MEPs. In a case series, Cantello and colleagues (2001) reviewed the use of MEPs for diagnosing psychogenic or hysterical paralysis. The authors concluded that MEP studies assisted in the diagnosis of psychogenic paralysis and noted that if nerve trunks and muscles were found to be intact, a psychogenic cause for paralysis may be implied. Additionally, specialty consensus review indicates that MEPs are useful in cases of hysterical or factitious paralysis. There is a lack of peer review literature to support the use of non-operative motor evoked potentials testing for other uses.
Friedreich's ataxia: A rare genetic disease that affects the muscles and heart.
Hysterical paralysis: An uncommon psychogenic, nonorganic loss of motor function.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Motor Evoked Potential
Motor Evoked Response
Somatosensory Evoked Potential
Somatosensory Evoked Response
Visual Evoked Potential
Visual Evoked Response
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||05/07/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Description, Discussion, Coding and Reference sections updated.|
|Reviewed||05/15/2014||MPTAC review. Discussion and Reference sections updated.|
|New||05/09/2013||MPTAC review. Initial document development.|