Anthem Blue Cross Connecticut CG-MED-94 Vestibular Function Testing Form

Subject:

Description

This document addresses the use of selected tests of vestibular function. Specifically, this document addresses the use of electronystagmography (ENG) and videonystagmography (VNG), caloric testing, and rotational chair testing.

Clinical Indications

Medically Necessary:

Vestibular function testing (that is, electronystagmography, videonystagmography, caloric testing, or rotational chair testing) is considered medically necessary under the following circumstances:

1. There are symptoms of a vestibular disorder (for example, dizziness, vertigo, imbalance); and
2. Diagnosis by clinical exam could not be established.

Not Medically Necessary:

Vestibular function testing is considered not medically necessary when the above criteria have not been met.