HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-7-028
Topic:
Electronystagmography and Videonystagmography Services
Section:
Diagnostic Medical
Effective Date:
September 9, 2024
Issued Date:
September 9, 2024
Last Revision Date:
February 2024
Annual Review:
February 2024
 
 

Electronystagmography (ENG) involves the electrical recording of involuntary eye movements. It is usually performed in the evaluation of dizziness, vertigo, or balance dysfunction. Metal electrodes are placed above, beside, and below each eye to detect eye movements.

Videonystagmography (VNG) provides vestibular examinations and performs electronystagmography without the use of electrodes. Such non-invasive video systems record, analyze, and report eye movements using video imaging technology. VNG requires the individual to wear a pair of infrared goggles and allows recording of actual video images of eye movement in real time.

Policy Position

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

·         The patient 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 function testing for the assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically is considered not medically necessary.

Repeat vestibular function testing when treatment resolves symptoms is considered not medically necessary.

Vestibular function testing not meeting the criteria as indicated in this policy is considered not medically necessary.

92537

92538

92540

92541

92542

92544

92545

92546

92547

92700

 

 

 

 


Vestibular evoked myogenic potential (VEMP) testing may be considered when ALL of the following conditions are met:

  • The individual does not have a diagnosis of benign paroxysmal positional vertigo; and
  • The individual has symptoms of superior semi-circular canal dehiscence (SCDS) (e.g. hearing loss, autophony, balance problems that are triggered by noise and/or activities that affect our inner ear pressure); and
  • The individual has had a comprehensive audiologic evaluation with results suggestive of SCDS.

Vestibular evoked myogenic potential (VEMP) tests not meeting the criteria as indicated in this policy are considered not medically necessary.

 

 

92517

92518

92519

 

 

 

 


When placement of vertical electrodes is reported with any of the above listed ENG services, the charges will be combined and only the ENG services(s) will be paid. When reported alone, placement of vertical electrodes will be denied as a non-covered service. 

92547

 

 

 

 

 

 


Covered diagnosis codes for procedure codes 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547

 

H81.01

H81.02

H81.03

H81.11

H81.12

H81.13

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.391

H81.392

H81.393

H81.4

H81.8X1

H81.8X2

H81.8X3

H81.91

H81.92

H81.93

H82.1

H82.2

H82.3

H83.01

H83.02

H83.03

H83.11

H83.12

H83.13

H83.2X1

H83.2X2

H83.2X3

H83.8X1

H83.8X2

H83.8X3

H83.91

H83.92

H83.93

R26.0

R26.1

R26.9

R26.81

R26.89

R42

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

An Electronystagmography (ENG) and Videonystagmography (VNG) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.