Anthem Blue Cross Connecticut CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials Form
This procedure is not covered
This document addresses non-operative uses of the following evoked potential (EP) studies:
- visual evoked potentials (VEPs);
- somatosensory evoked potentials (SSEPs or SEPs);
- motor evoked potentials (MEPs).
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. For additional information on intra-operative evoked potentials, please see CG-SURG-104 Intraoperative Neurophysiological Monitoring.
Clinical Indications
I. Visual Evoked Potentials:
Medically Necessary:
Visual evoked potentials are considered medically necessary for the diagnosis, evaluation, or monitoring of any of the following conditions:
- Multiple sclerosis or neuromyelitis optica, or other demyelinating disorders of the optic nerve; or
- Suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by magnetic resonance imaging, computerized tomography, infectious diseases or metabolic disorders.
Not Medically Necessary:
Visual evoked potentials are considered not medically necessary for all other uses, including but not limited to glaucoma testing and routine screening of infants.
II. Somatosensory Evoked Potentials:
Medically Necessary:
Somatosensory evoked potentials are considered medically necessary when the results will be used to guide clinical management for the following conditions:
- Acute (within 72 hours of onset) anoxic encephalopathy; or
- Coma following traumatic, hypoxic-ischemic and other diffuse brain injuries; or
- Central nervous system deficit identified on clinical exam when not explained by appropriate imaging studies; or
- Demyelinating disease (such as multiple sclerosis) when diagnosis is uncertain and clinical suspicion exists based on neurologic symptoms or cerebrospinal fluid evaluation; or
- Myelopathy, unexplained; or
- Spinocerebral degeneration (such as Friedreich’s ataxia); or
- Spinal cord lesions secondary to trauma when the need for surgical intervention is uncertain; or
- Suspected brain death.
Not Medically Necessary:
Somatosensory evoked potentials are considered not medically necessary for all other uses.
III. Motor Evoked Potentials:
Medically Necessary:
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.