Clinical UM Guideline

 

Subject: Visual, Somatosensory and Motor Evoked Potentials
Guideline #:  CG-MED-50 Publish Date:    12/27/2017
Status: Revised Last Review Date:    05/04/2017

Description

This document addresses non-operative uses of the following evoked potential (EP) studies:

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.

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:

  1. Multiple sclerosis or neuromyelitis optica, or other demyelinating disorders of the optic nerve; or
  2. 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:

  1. Acute (within 72 hours of onset) anoxic encephalopathy; or
  2. Coma following traumatic, hypoxic-ischemic and other diffuse brain injuries; or
  3. Central nervous system deficit identified on clinical exam when not explained by appropriate imaging studies; or
  4. Demyelinating disease (such as multiple sclerosis) when diagnosis is uncertain and clinical suspicion exists based on neurologic symptoms or cerebrospinal fluid evaluation; or
  5. Myelopathy, unexplained; or
  6. Spinocerebral degeneration (such as Friedreich's ataxia); or
  7. Spinal cord lesions secondary to trauma when the need for surgical intervention is uncertain; or
  8. Suspected brain death.

Not Medically Necessary:

Somatosensory evoked potentials are considered not medically necessary for all other uses.

III.  Motor evoked potential testing:

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.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

0333T

Visual evoked potential, screening of visual acuity, automated, with report

0464T

Visual evoked potential, testing for glaucoma, with interpretation and report

95925

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

95926

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs

95927

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head

95928

Central motor evoked potential study (transcranial motor stimulation); upper limbs

95929

Central motor evoked potential study (transcranial motor stimulation); lower limbs

95930

Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report

95938

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs

95939

Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs

 

 

ICD-10 Diagnosis

 

F44.4

Conversion disorder with motor symptom or deficit [hysterical paralysis]

F68.10-F68.13

Factitious disorder

G11.1-G11.9

Hereditary ataxia

G23.0-G23.9

Other degenerative diseases of basal ganglia

G35

Multiple sclerosis

G36.0-G36.9

Other acute disseminated demyelination

G37.0-G37.9

Other demyelinating disease of central nervous system

G93.1

Anoxic brain damage, not elsewhere classified

G93.82

Brain death

G95.9

Disease of spinal cord, unspecified (myelopathy NOS)

G97.81-G97.82

Other intraoperative and postprocedural complications and disorders of nervous system

H46.00-H46.9

Optic neuritis

H47.011-H47.49

Disorders of optic nerve, not elsewhere classified

H54.0-H54.8

Blindness and low vision

P84

Other problems with newborn (asphyxia of newborn NOS)

P91.60-P91.63

Hypoxic ischemic encephalopathy [HIE]

R40.20-R40.2444

Coma

S06.1X6A-S06.9X6S

Intracranial injury (with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving [code range with 6th character 6 and 7th character A-S]

S14.111A-S14.119S

Complete lesion of cervical spinal cord

S14.141A-S14.149S

Brown-Sequard syndrome of cervical spinal cord

S14.151A-S14.159S

Other incomplete lesions of cervical spinal cord

S24.111A-S24.119S

Complete lesion of thoracic spinal cord

S24.141A-S24.149S

Brown-Sequard syndrome of thoracic spinal cord

S24.151A-S24.159S

Other incomplete lesions of thoracic spinal cord

S34.111A-S34.119S

Complete lesion of lumbar spinal cord

S34.121A-S34.129S

Incomplete lesion of lumbar spinal cord

S34.131A-S34.139S

Other and unspecified injury to sacral spinal cord

S34.3XXA-S34.3XXS

Injury of cauda equina

Discussion/General Information

EPs are recordings of the nervous system's electrical response to the stimulation of specific sensory pathways. These recordings have the ability to provide information relative to the functional integrity of pathways within the nervous system. Only a few EPs are used on a routine basis and those most frequently encountered include VEPs and SSEPs.

Visual Evoked Potentials (VEPs)

VEPs track signals from the retina to the visual cortex and determine how a visual system reacts to light. A common indication for VEPs is to help confirm the diagnosis of MS, or to evaluate and monitor MS. In general, myelin plaques which occur in MS slow the speed of VEP wave peaks. Over time VEPs in individuals with MS become progressively slower eventually attenuating in amplitude as demyelination increases (Creel, 2012). The American Academy of Neurology (AAN) (Gronseth, 2000) recommends VEPs as probably useful to identify those at increased risk for clinically definite MS.

VEPs have also been used for other conditions including neuromyelitis optica (NMO) or other demyelinating disorders of the optic nerves, or for a suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by magnetic resonance imaging (MRI), computerized tomography (CT), infectious diseases or metabolic disorders.

The U.S. Preventive Services Task Force (USPSTF) (2011) has not recommended vision screening for infants and young children. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children less than 3 years of age.

van Laerhoven and colleagues (2013) performed a systematic literature review to investigate the prognostic value of current clinical tests used for evaluation of long-term neurodevelopmental outcome of neonates with perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE). A total of 29 studies were included in the review describing 13 prognostic tests performed 1631 times in 1306 term neonates. A considerable heterogeneity was noted in test performance, cut-off values, and outcome measures. The VEP (sensitivity 0.90 [0.74-0.97]; specificity 0.92 [0.68-0.98]) was found to be one of the most promising tests. The authors concluded that although the prognostic value of the test is promising, investigation in well-designed prospective studies is needed before standardized clinical use is advocated.

Several small studies (Horn, 2012; Pillai, 2013) have investigated the use of VEP technology to differentiate between normal healthy eyes and eyes with early to advanced visual field loss resulting from glaucoma. The authors indicated that VEP signals may discriminate between normal eyes and glaucomatous eyes. However, larger studies are needed to confirm these findings. Additionally, VEP has not been shown to be as good as or superior to standard visual field testing in managing clinical outcomes for persons with glaucoma.

Somatosensory Evoked Potentials (SSEPs)

SSEPs are electrical waves that are generated by the response of sensory neurons to stimulation. An abnormal SSEP finding demonstrates that there is dysfunction within the somatosensory pathways.

SSEP studies may be useful for helping to assess the extent of injury and predict outcomes in persons with traumatic, hypoxic-ischemic and other diffuse brain injuries, who are comatose. Rothstein (2009) studied 50 comatose individuals with preserved brainstem function after cardiac arrest. A total of 23 of the 50 had bilateral absence of cortical EPs and all died without awakening. Neuropathological study in seven of those that died displayed widespread ischemic changes or frank cortical laminar necrosis. The remaining 27 had normal or delayed central conduction times with some dying without awakening or entering a persistent vegetative state. The majority of individuals with normal central conduction times had good outcomes, whereas a delay in central conduction times increased the likelihood of neurologic deficit or death. It was noted that greater use of SSEPs in anoxic-ischemic coma and severe brain trauma would identify those persons unlikely to recover.

Wijdicks and colleagues (2006) for the Quality Standards Subcommittee of the American Academy of Neurology issued a practice parameter on "Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review)." The authors recommended that the assessment of poor prognosis can be guided by the bilateral absence of cortical SSEPs (N20 response) within 1 to 3 days (recommendation level B).

The American Academy of Neurology (AAN) (Gronseth, 2000) recommends SSEPs as possibly useful to identify those at increased risk of for developing clinically definite MS.

Additional indications for SSEPs include: acute anoxic encephalopathy; deficit of the central nervous system identified on exam, but not explained by appropriate imaging studies; demyelinating diseases under certain conditions; unexplained myelopathy; spinocerebral degeneration (such as Friedreich's ataxia); spinal cord lesions secondary to trauma when the need for surgical intervention is uncertain; or suspected brain death.

Motor Evoked Potentials (MEPs)

MEPs evaluate motor pathways located in the anterolateral spinal tracts perfused by the anterior spinal artery. Single- or repetitive-pulse stimulation of the brain causes the spinal cord and peripheral muscles to produce neuroelectrical signals known as MEPs. In a case series, Cantello and colleagues (2001) reviewed the use of MEPs for diagnosing psychogenic or hysterical paralysis. The authors concluded that MEP studies assisted in the diagnosis of psychogenic paralysis and noted that if nerve trunks and muscles were found to be intact, a psychogenic cause for paralysis may be implied. Additionally, specialty consensus review indicates that MEPs are useful in cases of hysterical or factitious paralysis. There is a lack of peer review literature to support the use of non-operative motor evoked potentials testing for other uses.

Definitions

Friedreich's ataxia: A rare genetic disease that affects the muscles and heart.

Hysterical paralysis: An uncommon psychogenic, nonorganic loss of motor function.

References

Peer Reviewed Publications:

  1. Cantello R, Boccagni C, Comi C, et al. Diagnosis of psychogenic paralysis: the role of motor evoked potentials. J Neurol. 2001; 248(10):889-897.
  2. Djuric S, Djuric V, Zivkovic M, et al. Are somatosensory evoked potentials of the tibial nerve the most sensitive test in diagnosing multiple sclerosis? Neurol India. 2010; 58(4):537-541.
  3. Horn FK, Kaltwasser C, Jünemann AG, et al. Objective perimetry using a four-channel multifocal VEP system: correlation with conventional perimetry and thickness of the retinal nerve fibre layer. Br J Ophthalmol. 2012; 96(4):554-559.
  4. Pillai C, Ritch R, Derr P, et al. Sensitivity and specificity of short-duration transient visual evoked potentials (SD-tVEP) in discriminating normal from glaucomatous eyes. Invest Ophthalmol Vis Sci. 2013; 54(4):2847-2852.
  5. Rothstein TL. The role of evoked potentials in anoxic-ischemic coma and severe brain trauma. J Clin Neurophysiol. 2000; 17(5):486-497.
  6. Sand T, Kvaløy MB, Wader T, Hovdal H. Evoked potential tests in clinical diagnosis. Tidsskr Nor Laegeforen. 2013; 133(9):960-965.
  7. van Laerhoven H, de Haan TR, Offringa M, et al. Prognostic tests in term neonates with hypoxic-ischemic encephalopathy: A systematic review. Pediatrics. 2013; 131(1):88-98.
  8. Young B, Eggenberger E, Kaufman D. Current electrophysiology in ophthalmology: a review. Curr Opin Ophthalmol. 2012; 23(6):497-505.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Creel DJ. Visually Evoked Potentials. 2012 Mar 01. In: Kolb H, Fernandez E, Nelson R, editors. Webvision: The Organization of the Retina and Visual System [Internet]. Salt Lake City (UT): University of Utah Health Sciences Center; 1995. Available at: http://www.ncbi.nlm.nih.gov/books/NBK107218/pdf/CreelVEP.pdf. Accessed on February 27, 2017.
  2. Gronseth GS, Ashman EJ. Practice parameter: the usefulness of evoked potentials in identifying clinically silent lesions in patients with suspected multiple sclerosis (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 54(9):1720-1725.
  3. U.S. Preventive Services Task Force. Screening for visual impairment in children ages 1 to 5 years. January 2011. Available at: http://www.uspreventiveservicestaskforce.org/uspstf11/vischildren/vischildrs.htm. Accessed on February 27, 2017.
  4. Wijdicks EF, Hijdra A, Young GB, et al; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006; 67(2):203-210.
Websites for Additional Information
  1. National MS Society. Evoked potentials. Available at: http://www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-Tools/Evoked-Potentials. Accessed on February 27, 2017.
Index

Motor Evoked Potential
Motor Evoked Response
Somatosensory Evoked Potential
Somatosensory Evoked Response
Visual Evoked Potential
Visual Evoked Response

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

  12/27/2017 The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT descriptor change for code 95930.
Revised 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Added glaucoma testing to not medically necessary statement for visual evoked potentials. Replaced "deficiency" with "deficit" in medically necessary statement for somatosensory evoked potentials. Formatting updated and abbreviations removed in Clinical Indications section. Discussion and References sections updated.
  01/01/2017 Updated Coding section with 01/01/2017 CPT changes.
  10/01/2016 Updated Coding section with 10/01/2016 ICD-10-CM diagnosis code changes.
Revised 05/05/2016 MPTAC review. Spelled out abbreviations in Clinical Indications section. Discussion and References sections updated. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Description, Discussion, Coding and References sections updated.
Reviewed 05/15/2014 MPTAC review. Discussion and References sections updated.
New 05/09/2013 MPTAC review. Initial document development.