Clinical Policy Title: Video head impulse testing

Clinical Policy Title: Video head impulse testing Clinical Policy Number: 09.01.16 Effective Date: March 1, 2018 Initial Review Date: January 11, 2018 Most Recent Review Date: February 6, 2018 Next Review Date: February 2019 Related policies: Policy contains: Vestibular function. Head impulse testing. Dizziness. Vertigo. CP# 10.01.03 CP# 09.01.13 CP# 09.01.06 Vestibular evoked myogenic potential testing Tilt table testing Brainstem auditory evoked response ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers the use of video head impulse testing to be clinically proven and, therefore, medically necessary to evaluate horizontal semicircular canal function, when all of the following criteria are met (Alhabib, 2017; American Speech-Language-Hearing Association [ASHA], 2017; Bhattacharyya, 2017; Cohen, 2017; Mezzalira, 2017; Skoric, 2017; Verbecque, 2017; Eza-Nunez, 2016; Ross, 2016; Fife, 2000): The member has symptoms of a vestibular disorder (e.g., dizziness, vertigo, imbalance, falls without other medical explanation). History and clinical evaluation, including the standard head impulse test, is inconclusive. The test results will aid in determining the appropriate medical or surgical treatment for disorders of auditory, balance, and other neural systems. 1

Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website may be accessed at http://ahca.myflorida.com/medicaid/. Video head impulse testing is not medically necessary as an initial, sole screening test for dizziness (Cohen, 2017; Mezzalira, 2017). Alternative covered services: Computerized dynamic posturography. Electronystagmography or videonystagmography. Caloric testing. Rotation testing. Qualitative vestibular assessment. Scleral search coil method. Specialty referral. Standard of care diagnostic testing (e.g., audiometry, visual acuity examination, radiography, and blood work). Background Dizziness (including vertigo) affects approximately 15 percent to 30 percent of the general population, and its prevalence rises with age. The most common causes of dizziness are vestibular disorders (Neuhauser, 2016; Piker, 2016). Congenital or acquired conditions resulting from disease or injury to the vestibular system may reduce vision and depth perception and alter balance and coordination (ASHA, 2017). The vestibular system comprises parts of the central nervous system that help process balance and spatial information and the peripheral organs of the inner ear. The peripheral vestibular organs provide input to vestibulo-ocular reflex in response to head movement and position; these organs comprise the eighth cranial nerve and the horizontal, anterior, and posterior semicircular canals and otolith organs (utricle and saccule) of the vestibular labyrinth (ASHA, 2017). A battery of non-instrumented tests (direct observation) and instrumented tests using both static and dynamic measures may be performed at the bedside or in an office setting to discern the etiology of vestibular dysfunction (ASHA, 2017). Within the context of the individual's medical history, diagnostic testing is performed to differentiate peripheral and central etiologies based on response to visual fixation and the presence and direction of nystagmus, which is a vision condition characterized by 2

involuntary, rapid, and repetitive horizontal, vertical, or circular movement of the eyes (American Academy of Ophthalmology, 2017). Standard and video head impulse tests: The standard head impulse test, also known as a head thrust test, impulse rotational test, or vestibuloocular reflex test, is used to assess horizontal semicircular canal function (Halmagyi, 2017). During a standard, non-instrumented head impulse test, the clinician rotates the patient s head abruptly and unpredictably in the vertical axis of the head while the patient keeps a fixed gaze on a target. A patient with vestibular impairment will move his or her eyes with the head, forcing a corrective eye movement (saccade) at the end of each head impulse to return to the target. Results may demonstrate a problem with semicircular canal function on the same side to which the head was turned prior to the corrective refixation response. The standard procedure is noninvasive, safe, easy, and uses stimuli in the physiological range of everyday head movement, but it lacks objective documentation. The video version images the eye using sophisticated eye tracking and head velocity transducers, providing an objective record of eye movement and head movement during head impulses. Searches Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on December 12, 2017. Search terms were: Head Impulse Test (MeSH), Vestibular Function Tests (MeSH), and free text terms head impulse test, thrust test, vestibuloocular reflex, and vestibulo-ocular." We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. 3

Findings We identified three systematic reviews (Abouzayd, 2017; Alhabib, 2017; Verbecque, 2017), four prospective non-randomized comparative studies (Cohen, 2017; Mezzalira, 2017; Eza-Nunez, 2016; Ross, 2016), one retrospective comparative study (Skoric, 2017), and three evidence-based guidelines (ASHA, 2017; Bhattacharyya, 2017; Fife, 2000) for this policy. The comparative diagnostic efficacy of video head impulse testing and other vestibular function tests is based on retrospective and prospective nonrandomized cohort studies of low to moderate quality. Caloric testing, cervical vestibular evoked myogenic potentials, un-instrumented head impulse tests, head shaking tests, and rotational chair tests were the most common comparators. Few studies compared video head impulse testing to the scleral search coil method, which is considered a gold standard for accurate measurement of high velocity eye movements but is cumbersome to perform and non-portable. The results suggest video head impulse testing provides distinct but complementary diagnostic information in the work up of persons with vestibular complaints when the clinical examination is inconclusive. Limited evidence suggests quantifying eye movement with video head impulse testing may improve the ability to detect unobservable, covert saccades that occur during head impulses compared to its non-quantitative counterpart (Alhabib, 2017; Cohen, 2017). There is an absence of evidence-based guidelines regarding which diagnostic algorithms should be applied to which patients among the clinically heterogeneous group that presents with dizziness. Evidence-based guidelines agree that quantitative vestibular tests may be useful in evaluating vestibular disorders that may not be evident from the history and clinical examination (ASHA, 2017; Bhattacharyya, 2017; Fife, 2000). The choice of tests should be based on a case-by-case strategy according to each patient's symptoms and their suspected origin, and equipment availability. Policy updates: None. Summary of clinical evidence: Citation Abouzayd (2017) What vestibular tests to choose in symptomatic patients after a cochlear implant? Content, Methods, Recommendations Systematic review and meta-analysis of 16 studies, representing 957 patients. Sensitivity results (mean, 95% confidence interval): caloric tests (0.21, 0.08, to 0.40), cervical vestibular evoked myogenic potentials (0.32, 0.15, to 0.54), and head impulse tests (0.5, 0.07, to 0.93). No vestibular test is sensitive enough to be recommended as a single test, but choice of tests should be based on a case-by-case strategy according to each patient's symptoms and their suspected origin. 4

Citation Alhabib (2017) Video head impulse test: a review of the literature Cohen (2017) Utility of quick oculomotor tests for screening the vestibular system in the subacute and chronic populations Mezzalira (2017) Sensitivity of caloric test and video head impulse as screening test for chronic vestibular complaints Skoric (2017) Content, Methods, Recommendations Review of 37 studies that defined the test and studied its comparative diagnostic efficacy for vestibular disease. Four testing systems were represented in the literature. Video head impulse test is more sensitive than standard head impulse test, especially in patient with isolated covert saccades. Recommendations: - If the test is normal, then caloric test is mandatory to rule out a peripheral origin of vertigo. - Test each semicircular canal, as isolated vertical canal weakness can occur. - More investigation needed to determine the natural evolution of the vestibuleocular reflex gain with the progression of the vestibular disease. Prospective comparison of passive and active head shaking, un-instrumented head impulse tests, and video head impulse tests recorded with infrared video-oculography in 291 healthy controls with no history of otologic or neurologic disorders and 62 patients with known vestibular disorders. Sensitivity of presence or absence of vertigo and of nystagmus for both passive and active head shaking, presence or absence of saccades on un-instrumented head impulse tests, and gain on video head impulse testing was < 0.40, < 0.15, and approximately 0.15 to 0.35, respectively. None of these tests is adequate for screening patients in the outpatient clinic for vestibular disorders or for screening people in epidemiologic studies to determine the prevalence of vestibular disorders. Prospective, multicenter cross-sectional cohort study of 157 participants (88 women and 69 men; mean age 49 ± 16.7 years) referred to a specialty neurotology outpatient clinic. After standard clinical testing, the caloric and video head impulse tests were applied. Significantly more caloric test results than video head impulse test results were abnormal (Fisher s exact test, p = 0.008); the proportion was 3:1. The probability of diagnosing a vestibular dysfunction via caloric testing was 72% versus 26% with video head impulse testing. No correlation found between the two results. The caloric test and video head impulse test are distinct but complementary; the latter test is not a suitable screening tool in patients with chronic vestibular complaints. Vestibular evoked myogenic potentials and video head impulse test in patients with vertigo, dizziness, and imbalance Retrospective analysis comparing vestibular evoked myogenic potentials and video head impulse test results in 117 patients (73 females, mean age 53.92 ± 16.76) who presented with vertigo and dizziness from January 2015 to January 2016. Group 1 included patients with vestibular neuritis (16 right and 15 left), group 2 included patients with vertigo of central origin (N = 23), and group 3 included patients with unspecified dizziness (N = 63). 5

Citation Verbecque (2017) Vestibular (dys)function in children with sensorineural hearing loss: a systematic review Eza-Nunez (2016) Comparison of three diagnostic tests in detecting vestibular deficit in patients with peripheral vestibulopathy Ross (2016) Content, Methods, Recommendations Asymmetries on both tests were significantly greater and were significantly correlated (r = 0.749, p < 0.001), in patients with vestibular neuritis than in the other groups. Data from both tests are complementary; asymmetry on both tests strongly supports peripheral vestibular system involvement. Vestibular function differs significantly between children with hearing loss and normal hearing (p < 0.05). Sensitivity and specificity using caloric testing as the reference standard: - Rotational chair test 61% to 80% and 21% to 80%, respectively. - Collic vestibular evoked myogenic potentials 71% to 100% and 30% to 100%, respectively. Sensitivity and specificity using rotational chair test as the reference standard: - Dynamic visual acuity test 88% to 100% and 69% to 100%, respectively. - Video head impulse test 67% to 100% and 71% to 100%, respectively. - Ocular vestibular evoked myogenic potentials 83% and 86%, respectively. Due to methodological shortcoming, evidence on sensitivity and specificity of vestibular tests is unknown to moderate. Future research should focus on adequate sample sizes (subgroups > 30). A prospective comparison of the video head impulse test, caloric test, and rotatory chair test in 116 patients (75 with a peripheral vestibulopathy, 41 with non-peripheral vestibulopathy). Low agreement between tests for assessment of horizontal semicircular canal function. Vestibulopathy testing that required all three results to be abnormal had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.547, 0.878, 0.891, and 0.514, respectively. Vestibulopathy testing that required just one result to be abnormal had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.933, 0.292, 0.701, and 0.705, respectively. The video head impulse test had sufficient statistical power to be recommended as the first-line test. Test-retest and interrater reliability of the video head impulse test in the pediatric population Reliability study of two normal adults, mean age 51.5 ± 0.5 years and 28 typically developing children and adolescents, mean age 10 ± 3.5 years (range, 4.33 to 17.25 years). Mean angular vestibular ocular reflex gain intra-rater reliability scores and inter-rater reliability scores showed good consistency. In pediatric populations, the video head impulse test was a reliable clinical test to quantify individual canal function using high-velocity head impulses, but it was difficult to acquire head impulse velocities of > 100 degrees per second, especially in the plane of the vertical canals, required to reveal asymmetry in compensatory eye movements. 6

References Professional society guidelines/other: What Is Nystagmus? American Academy of Ophthalmology website. https://www.aao.org/eyehealth/diseases/what-is-nystagmus. Accessed December 12, 2017. Balance System Disorders. American Speech-Language-Hearing Association website. https://www.asha.org/prpspecifictopic.aspx?folderid=8589942134&section=assessment. Accessed December 12, 2017. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017; 156(3_suppl): S1 s47. DOI: 10.1177/0194599816689667. Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and children: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000; 55(10): 1431 1441. American Academy of Neurology website. http://n.neurology.org/content/neurology/55/10/1431.full.pdf. Accessed December 13, 2017. (Update in progress). Peer-reviewed references: Abouzayd M, Smith PF, Moreau S, Hitier M. What vestibular tests to choose in symptomatic patients after a cochlear implant? A systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2017; 274(1): 53 63. DOI: 10.1007/s00405-016-4007-4. Alhabib SF, Saliba I. Video head impulse test: a review of the literature. Eur Arch Otorhinolaryngol. 2017; 274(3): 1215 1222. DOI: 10.1007/s00405-016-4157-4. Bartolomeo M, Biboulet R, Pierre G, et al. Value of the video head impulse test in assessing vestibular deficits following vestibular neuritis. Eur Arch Otorhinolaryngol. 2014; 271(4): 681 688. DOI: 10.1007/s00405-013-2451-y. Cohen HS, Stitz J, Sangi-Haghpeykar H, et al. Utility of quick oculomotor tests for screening the vestibular system in the subacute and chronic populations. Acta Otolaryngol. 2017: 1 5. DOI: 10.1080/00016489.2017.1398838. Eza-Nunez P, Farinas-Alvarez C, Fernandez NP. Comparison of three diagnostic tests in detecting vestibular deficit in patients with peripheral vestibulopathy. J Laryngol Otol. 2016; 130(2): 145 150. DOI: 10.1017/s0022215115003114. 7

Halmagyi GM, Chen L, MacDougall HG, et al. The Video Head Impulse Test. Front Neurol. 2017; 8: 258. DOI: 10.3389/fneur.2017.00258. Mezzalira R, Bittar RSM, do Carmo Bilecki-Stipsky MM, Brugnera C, Grasel SS. Sensitivity of caloric test and video head impulse as screening test for chronic vestibular complaints. Clinics (Sao Paulo). 2017; 72(8): 469 473. DOI: 10.6061/clinics/2017(08)03. Neuhauser HK. The epidemiology of dizziness and vertigo. Handb Clin Neurol. 2016; 137: 67 82. DOI: 10.1016/b978-0-444-63437-5.00005-4. Piker EG, Schulz K, Parham K, et al. Variation in the Use of Vestibular Diagnostic Testing for Patients Presenting to Otolaryngology Clinics with Dizziness. Otolaryngol Head Neck Surg. 2016; 155(1): 42 47. DOI: 10.1177/0194599816650173. Ross LM, Helminski JO. Test-retest and Interrater Reliability of the Video Head Impulse Test in the Pediatric Population. Otol Neurotol. 2016; 37(5): 558 563. DOI: 10.1097/mao.0000000000001040. Skoric MK, Adamec I, Pavicic T, et al. Vestibular evoked myogenic potentials and video head impulse test in patients with vertigo, dizziness and imbalance. J Clin Neurosci. 2017; 39: 216 220. DOI: 10.1016/j.jocn.2017.02.009. Verbecque E, Marijnissen T, De Belder N, et al. Vestibular (dys)function in children with sensorineural hearing loss: a systematic review. Int J Audiol. 2017; 56(6): 361 381. DOI: 10.1080/14992027.2017.1281444. CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. A54818 Vestibular Function Testing - coding guidelines. CMS website. https://www.cms.gov/medicarecoverage-database/details/article-details.aspx?articleid=54818&ver=2. Accessed December 14, 2017. Local Coverage Determinations (LCDs): L35007 Vestibular and Audiologic Function Studies. CMS website. https://www.cms.gov/medicarecoverage-database/details/lcd-details.aspx?lcdid=35007&ver=66. Accessed December 14, 2017. L34537 Vestibular Function Testing. CMS website. https://www.cms.gov/medicare-coveragedatabase/details/lcd-details.aspx?lcdid=34537&ver=28. Accessed December 14, 2017. L33966 Vestibular Function Tests. CMS website. https://www.cms.gov/medicare-coveragedatabase/details/lcd-details.aspx?lcdid=33966&ver=8. Accessed December 14, 2017. 8

Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments 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) Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, 92540 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) 92548 Computerized dynamic posturography 92552 Pure tone audiometry (threshold); air only 92553 Pure tone audiometry (threshold); air and bone 92556 Speech audiometry threshold; with speech recognition 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) ICD-10 Code Description Comments H81.01 Meniere's disease, right ear H81.02 Meniere's disease, left ear H81.03 Meniere's disease, bilateral H81.11 Benign paroxysmal vertigo, right ear H81.12 Benign paroxysmal vertigo, left ear H81.13 Benign paroxysmal vertigo, bilateral H81.21 Vestibular neuronitis, right ear H81.22 Vestibular neuronitis, left ear H81.23 Vestibular neuronitis, bilateral H81.311 Aural vertigo, right ear H81.312 Aural vertigo, left ear H81.313 Aural vertigo, bilateral 9

ICD-10 Code Description Comments H81.391 Other peripheral vertigo, right ear H81.392 Other peripheral vertigo, left ear H81.393 Other peripheral vertigo, bilateral H81.41 Vertigo of central origin, right ear H81.42 Vertigo of central origin, left ear H81.43 Vertigo of central origin, bilateral H81.8X1 Other disorders of vestibular function, right ear H81.8X2 Other disorders of vestibular function, left ear H81.8X3 Other disorders of vestibular function, bilateral H81.91 Unspecified disorder of vestibular function, right ear H81.92 Unspecified disorder of vestibular function, left ear H81.93 Unspecified disorder of vestibular function, bilateral H82.1 Vertiginous syndromes in diseases classified elsewhere, right ear H82.2 Vertiginous syndromes in diseases classified elsewhere, left ear H82.3 Vertiginous syndromes in diseases classified elsewhere, bilateral H83.01 Labyrinthitis, right ear H83.02 Labyrinthitis, left ear H83.03 Labyrinthitis, bilateral H83.11 Labyrinthine fistula, right ear H83.12 Labyrinthine fistula, left ear H83.13 Labyrinthine fistula, bilateral H83.2X1 Labyrinthine dysfunction, right ear H83.2X2 Labyrinthine dysfunction, left ear H83.2X3 Labyrinthine dysfunction, bilateral H83.8X1 Other specified diseases of right inner ear H83.8X2 Other specified diseases of left inner ear H83.8X3 Other specified diseases of inner ear, bilateral H83.91 Unspecified disease of right inner ear H83.92 Unspecified disease of left inner ear H83.93 Unspecified disease of inner ear, bilateral H90.0 Conductive hearing loss, bilateral H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the H90.3* Sensorineural hearing loss, bilateral H90.41* Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the H90.42* Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the H90.71 Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the H90.72 Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the 10

ICD-10 Code Description Comments H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the H90.A21* Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the H90.A22* Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the H90.A31* Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the H90.A32* Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the R42 Dizziness and giddiness HCPCS Level II Code N/A Description N/A Comments 11