024 Form

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Medical Policy Vestibular Function Testing Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 024 BCBSA Reference Number: 2.01.104 (For Plan internal use only) NCD/LCD: N/A
Related Policies
Dynamic Posturography, #263
Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Vestibular function testing using an electronystagmography and videonystagmography testing batteries, caloric testing, or rotational chair testing may be considered MEDICALLY NECESSARY when the following conditions have been met:

• The individual has symptoms of a vestibular disorder (eg, dizziness, vertigo, imbalance); AND • A clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has failed to identify the cause of the symptoms.

Vestibular evoked myogenic potential (VEMP) testing for the diagnostic evaluation or to determine the appropriate medical or surgical treatment may be considered MEDICALLY NECESSARY when the following conditions have been met: • The patient has symptoms that may be suggestive of optic capsule dehiscence (semicircular canal or other dehiscences (e.g., noise/sound induced dizziness [Tullio phenomenon], fullness/pressure in the ear, autophony)

Vestibular function testing for the assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically is INVESTIGATIONAL..

Repeat vestibular function testing when treatment resolves symptoms is INVESTIGATIONAL.

Vestibular function testing in all other situations is INVESTIGATIONAL.

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All other laboratory-based vestibular function tests not described above are considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes
CPT codes: Code Description 92517 Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) 92518 Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP) 92519 Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP 92537 Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) 92538 Caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations) 92540 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542 Positional nystagmus test, minimum of 4 positions, with recording 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording 92545 Oscillating tracking test, with recording 92546 Sinusoidal vertical axis rotational testing 92547
Use of vertical electrodes (List separately in addition to code for primary procedure)

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Description Vertigo The vestibular system is an important component in balance control. It includes 5 end organs, 3 semicircular canals sensitive to head rotations, and 2 otolith organs (saccule, utricle) that sense gravity and straight-line (forward, backward, left, right, downward or upward) accelerations. Vertigo is the primary symptom of vestibular dysfunction. It can be experienced as illusory movements such as spinning, swaying, or tilting. Vertigo may be associated with a feeling of being pushed or pulled to the ground, blurred vision, nausea and vomiting, or postural and gait instability. Vertigo may arise from damage or dysfunction of the vestibular labyrinth, vestibular nerve, or central vestibular structures in the brainstem.

Vertigo may be caused by loose particles (otoconia) from the otolith organs that pass into 1 of the semicircular canals, most frequently the posterior canal. Specific head movements cause the particle to stimulate the canal, causing brief benign paroxysmal positional vertigo.

Diagnosis Brief benign paroxysmal positional vertigo can usually be diagnosed clinically based on a history of positional vertigo, response to the Dix-Hallpike maneuver or lateral roll tests, and resolution of symptoms with canal repositioning maneuvers.

If vertigo cannot be attributed to benign paroxysmal positional vertigo based on history, symptoms, or response to the standard maneuvers, a number of laboratory-based tests can be used to determine whether the vertigo is due to loss of vestibular function.1,2, These tests are based on the vestibulo-ocular reflex, which is an involuntary beating movement of the eyes (nystagmus) in response to vestibular stimulation. Nystagmus induced by these tests can help to distinguish between central and peripheral etiologies, in addition to determining whether the deficit is unilateral or bilateral. The typical tests include the electronystagmography (ENG) or videonystagmography (VNG) test batteries, caloric testing, and rotational chair testing.

Electronystagmography/Videonystagmography Test Batteries The ENG/VNG test batteries include oculomotor evaluation and positional testing. Electronystagmography uses electrodes at the canthus of the eyes to detect nystagmus while VNG uses infrared video monitoring with goggles to measure nystagmus.

Caloric Testing Caloric testing evaluates unilateral vestibular function. In the caloric test, warm or cold water or warm or cold air is introduced into each of the external ear canals. In some descriptions, caloric testing is conducted as part of ENG/VNG test batteries.

Rotational Chair Testing Rotational chair testing evaluates bilateral vestibular function. Rotational chair devices include a lightproof booth, computer-driven chair with a head restraint that rotates around a vertical axis, ENG recording, an infrared camera, and a 2-way communication system. Typically, the chair is rotated in 4 different patterns, constant acceleration followed by deceleration, rotating followed by a rapid stop, rotating at progressively increasing velocities, and alternating directions.

Passive rotational testing without a rotational chair may be performed when the rotational chair is not available. For the head impulse test, the patient is instructed to keep his or her eyes on a target. The examiner then turns the head rapidly by about 15°. With passive whole-body testing, the examiner rotates the whole body to the rhythm of a metronome.

Vestibular Evoked Myogenic Potential Testing Vestibular evoked myogenic potential (VEMP) tests are newer techniques that use loud sound (eg, click, tone burst) or bone vibration (eg, tendon hammer tap to the forehead or mastoid) to assess otolith function.3, Both the saccule and utricle are sensitive to sound as well as vibration and movement.

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Cervical VEMPs are measured by surface electrodes on the ipsilateral sternocleidomastoid muscle in the neck and are thought to originate primarily in the saccule. Abnormality in any part of the auditory cervical VEMP pathway (saccule, inferior vestibular nerve, vestibular nucleus, medial vestibulospinal tract, the accessory nucleus, the eleventh nerve, sternocleidomastoid) can affect the response.

Ocular VEMPs detect subtle activity of an extraocular muscle using surface electrodes under the contralateral eye during an upward gaze and are thought to be due primarily to stimulation of the utricle. The vestibulo-ocular reflex stimulated by sound or vibration is very small, but synchronous bursts of activity of the extraocular muscles can be detected by electromyography. Lesions that affect the ocular VEMP may occur in the utricle, superior vestibular nerve, vestibular nucleus, and the crossed vestibulo-ocular reflex pathways.

Dynamic Posturography Dynamic posturography may also be used to evaluate balance. Dynamic posturography is discussed in policy #263.

Treatment The central vestibular system is able to compensate for loss of peripheral vestibular function. Thus, the primary therapy for peripheral vestibular dysfunction is exercise-based and includes exercises to promote gaze stability, habituate symptoms, and improve balance and gait.4, Medications such as vestibular suppressants or antiemetics may be used in the acute stage but are not recommended for chronic use. For patients who have recurrent symptoms uncontrolled by other methods, a surgical or ablative approach may be used. The objective of ablation is to stabilize the deficit to allow central compensation.

Summary Description Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. A number of established laboratory-based 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 and videonystagmography test batteries, caloric stimulation, and rotational chair testing. Vestibular evoked myogenic potentials (VEMPs), triggered by sound and vibration, are also being evaluated for the diagnosis of otolith dysfunction.

Summary of Evidence Undiagnosed Benign Paroxysmal Positional Vertigo For individuals who have a suspected vestibular disorder not clinically diagnosed as benign paroxysmal positional vertigo (BPPV) who receive electronystagmography/videonystagmography test batteries, caloric testing, or rotational chair testing, the evidence includes technology assessments of a large body of literature. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. Based on review of controlled studies, caloric testing was given a level A recommendation that this test is predictive of loss of vestibular function. Based on a prospective study assessing a narrow spectrum of patients with the suspected vestibular dysfunction and a well-designed retrospective study, which included a criterion standard test, rotational chair testing was also given a level A recommendation. These tests are both considered criterion standard tests of vestibular function. Electronystagmography/videonystagmography test batteries, which may include caloric testing, are also established methods of assessing loss of vestibular function. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have a suspected vestibular disorder not clinically diagnosed as benign paroxysmal positional vertigo (BPPV) who receive vestibular evoked myogenic potentials (VEMP) testing, the evidence includes mainly association studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. There is a large and rapidly growing literature on VEMP tests for the assessment of otolith function, although most studies have assessed how the cervical VEMP and ocular VEMP change with various disease states. Studies on diagnostic accuracy and clinical utility of this technique for evaluating

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otolith organs and central pathways are needed in the appropriate populations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Diagnosed Benign Paroxysmal Positional Vertigo For individuals who have clinically diagnosed benign paroxysmal positional vertigo(BPPV) with typical presentation who receive laboratory-based vestibular function testing, the evidence includes technology assessments and practice guidelines. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of life. Benign paroxysmal positional vertigo with a typical presentation can be diagnosed clinically based on history, the Dix-Hallpike maneuver, lateral roll test, and canalith repositioning procedures; thus, laboratory-based vestibular function testing does not add diagnostic information in such routine cases. The evidence is sufficient to determine that the technology is unlikely to improve the net health outcome. Policy History Date Action 4/2026 Annual policy review. Policy updated with literature review through December 17, 2025; references added. Policy statements unchanged. 4/2024 Annual policy review. References updated. Policy statements unchanged. 7/2024 Clarified coding information 4/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2023 Annual policy review. Minor editorial refinements to policy statements; intent unchanged. 10/2022 New medically necessary indications described for VEMP testing. References and summary section updated. Coding clarified. Effective 10/1/22.
4/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Clarified coding information 4/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2018 Annual policy review. Background clarified.
3/2018 Annual review. New references added. Background and summary clarified.
8/2017 New medical policy describing medically necessary and investigational indications.
Effective 8/1/2017. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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2. Schubert MC. Vestibular function tests. In: Herdman SJ, Clendaniel RA, eds. Vestibular Rehabilitation. Vol Contemporary Perspectives in Rehabilitation: F.A. Davis; 2014:178-194.
3. 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.
4. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL

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THERAPY ASSOCIATION NEUROLOGY SECTION. J Neurol Phys Ther. Apr 2016; 40(2): 124-55. PMID 26913496

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7. Weber KP, Rosengren SM. Clinical utility of ocular vestibular-evoked myogenic potentials (oVEMPs). Curr Neurol Neurosci Rep. May 2015; 15(5): 22. PMID 25773001
8. Welgampola MS, Colebatch JG. Vestibulocollic reflexes: normal values and the effect of age. Clin Neurophysiol. Nov 2001; 112(11): 1971-9. PMID 11682335
9. 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. Feb 2016; 273(2): 317-23. PMID 25628238
10. Du Y, Tang C, Ren L, et al. Assessing otolith dysfunction in Meniere's disease: insights from multi- frequency vestibular evoked myogenic potential testing. Int J Audiol. Oct 2025; 64(10): 1035-1044. PMID 39991949
11. Verrecchia L, Brantberg K, Tawfique Z, et al. Diagnostic Accuracy of Ocular Vestibular Evoked Myogenic Potentials for Superior Canal Dehiscence Syndrome in a Large Cohort of Dizzy Patients. Ear Hear. 2019; 40(2): 287-294. PMID 29889159
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13. 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. May 2008; 14(3): 201-4. PMID 18469678
14. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008; 139(5 Suppl 4): S47-81. PMID 18973840
15. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. Mar 2017; 156(3_suppl): S1-S47. PMID 28248609
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