VESTIBULAR FUNCTION TESTING

Transcription

1 VESTIBULAR FUNCTION TESTING Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. O docx Page 1 of 7

2 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 vestibule-ocular reflex, which is an involuntary movement of the eyes (nystagmus) in response to vestibular stimulation. Established laboratory tests include electronystagmography (ENG) and videonystagmography (VNG) test batteries, caloric stimulation, and rotational chair testing. Vestibular evoked myogenic potentials (VEMPs), triggered by sound and vibration, are also being investigated for the diagnosis of otolith dysfunction. Vertigo is the primary symptom of vestibular dysfunction. It can be experienced as illusory movement 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 the 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 one 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 (BPPV). BPPV can usually be diagnosed clinically based on history of positional vertigo, response to the Dix-hallpike maneuver or lateral roll tests, and resolution of symptoms with canal repositioning maneuvers. Definitions: Dix-Hallpike Maneuver: Vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the individual from an upright to supine position with the head turned 45 to 1 side and neck extended 20 with the affected ear down. 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. ENG/VNG Test Batteries: The ENG/VNG test batteries include oculomotor evaluation and positional testing. ENG uses electrodes at the canthus of the eyes to detect nystagmus while VNG uses infrared video monitoring with goggles to measure nystagmus. O docx Page 2 of 7

3 Definitions: (cont.) Rotational Chair Testing: The rotational chair test 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, increasing velocities, and alternating directions. Vestibular Evoked Myogenic Potential Testing: VEMP tests are newer techniques that use loud sound (e.g., click, tone burst) or bone vibration (e.g., tendon hammer tap to the forehead or mastoid) to assess otolith function. Both the saccule and utricle are sensitive to sound as well as vibration and movement. An example of equipment used for VEMP testing is the Bio-Logic Nav-Pro, which was cleared for marketing by the FDA through the 510(K) process in Cervical VEMPs (cvemps) are measured by surface electrodes on the ipsilateral sternocleidomastoid (SCM) muscle in the neck and are thought to originate primarily in the saccule. Ocular VEMPs (ovemps) 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. Vestibular analysis devices include, but are not limited to: Chair, Vestibular, Rotary, Computerized Epley Omniax EquiTest ICS Impulse Nydiag 200 Rotary Chair RVT-50 Rotary Chair for Vestibular Testing Sway Balance VMT System VORTEQ (Vestibular Ocular Reflex Test Equipment) O docx Page 3 of 7

4 Criteria: For dynamic posturography, see BCBSAZ Medical Coverage Guideline #O58, Dynamic Posturography. Vestibular function testing using electronystagmography and videonystagmography testing batteries, caloric testing or rotational chair testing is considered medically necessary with documentation of ALL of the following: 1. Individual has symptoms of a vestibular disorder (e.g., dizziness, vertigo, imbalance) 2. 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. All other laboratory-based vestibular function tests for all other indications not previously listed or if above criteria not met is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 4. Insufficient evidence to support improvement outside the investigational setting. These tests include, but are not limited to: Vestibular evoked myogenic potential (VEMP) tests O docx Page 4 of 7

5 Resources: Literature reviewed 03/20/18. We do not include marketing materials, poster boards and nonpublished literature in our review. The BCBS Association Medical Policy Reference Manual (MPRM) policy is included in our guideline review. References cited in the MPRM policy are not duplicated on this guideline BCBS Association Medical Policy Reference Manual. Vestibular Function Testing. Re-issue date 02/08/2018, issue date 03/09/ 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. O docx Page 5 of 7

6 Non-Discrimination Statement: Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) for Spanish and (877) for all other languages and other aids and services. If you believe that BCBSAZ 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: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , (602) , TTY/TDD (602) , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s 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 or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Multi-Language Interpreter Services: O docx Page 6 of 7

7 Multi-Language Interpreter Services: (cont.) O docx Page 7 of 7