DESCRIPTION
Canalith repositioning is a non-surgical procedure performed in an outpatient setting to treat benign paroxysmal positional vertigo (BPPV). BPPV is a type of vertigo caused by displaced debris in the semicircular canals of the ear resulting in the sensation of rotation and movement. Canalith repositioning involves a series of maneuvers, rotating the head and body, to relocate debris from the semicircular canal into the utricle where they are harmless. There are two methods for this procedure, Epley maneuver and the Sermont maneuver.
POLICY
Canalith repositioning for the evaluation and management of benign paroxysmal positional vertigo is considered medically necessary.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American Speech-Language-Hearing Association. (1999). Role of audiologists in vestibular and balance rehabilitation: Position statement. Retrieved October 11, 2010 from http://www.asha.org/docs/pdf/PS1999-00037.pdf.
Bhattacharyya, N., Baugh, R. F., Orvidas, L., Barrs, D., Bronston, L. J., Cass, S., et al. (2008). Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology and Head and Neck Surgery, 139 (5 Suppl. 4), S47-S81.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2004). Canalith repositioning as a treatment of benign paroxysmal positional vertigo (BPPV) (2.01.37). Retrieved October 11, 2010 from BlueWeb. (11 articles and/or guidelines reviewed)
Cakir, B. O., Ercan, I., Cakir, Z. A., & Turgut, S. (2006). Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Archives of Otolaryngology-Head & Neck Surgery, 132 (5), 501-505. (Level 3 Evidence - Independent study)
ECRI Institute. Health Technology Information Service. Evidence Reports. (2006, October). Vestibular rehabilitation and particle repositioning for benign positional vertigo. Retrieved October 11, 2010 from ECRI Institute. (84 articles and/or guidelines reviewed)
Fife, T. D., Iverson, D. J., Lempert, T., Furman, J. M., Baloh, R. W., et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70 (22), 2067-2074.
Munoz, J. E., Miklea, J. T., Howard, M., Springate, R., & Kaczorowski, L. (2007). Canalith repositioning maneuver for benign paroxysmal positional vertigo: Randomized controlled trial in family practice. Canadian Family Physician, 53 (6), 1048-1053. (Level 2 Evidence - Independent study)
ORIGINAL EFFECTIVE DATE: 12/1/2001
MOST RECENT REVIEW DATE: 11/11/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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