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 Sermont Maneuver.
POLICY
Canalith repositioning for the evaluation and management of benign paroxysmal positional vertigo is considered medically necessary.
SOURCES
American Speech-Language-Hearing Association. (1999, March). Role of audiologist in vestibular and balance rehabilitation: Position statement, guidelines, and technical report. Asha, 41 (Suppl. 19), 13-22. Retrieved June 12, 2001 from: http://professional.asha.org/audiology/images/vestib&balrehab.pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2004, January). Canalith repositioning as a treatment of benign paroxysmal positional vertigo (BPPV) (2.01.37). Retrieved March 6, 2008 from BlueWeb. (11 articles and/or guidelines reviewed)
ECRI Institute. Health Technology Assessment Information Service. Windows on Medical Technology. (2003, January). Vestibular rehabilitation and particle repositioning for benign positional vertigo. Retrieved March 5, 2003 from ECRI Institute. (84 articles and/or guidelines reviewed)
Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD—3162. DOI: 10.1002/14651858.CD003162.pub2.
Prokopakis, E. P., Chimona, T., Tsagournisakis, M., Christodoulou, P., Hirsch, B. E., Lachanas, V. A., et al. (2005). Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. The Laryngoscope, 115 (9), 1667-1671. Abstract retrieved March 6, 2008 from PubMed database.
Tevzadze, N., Shakarishvili, R. (2007). Effectiveness of canalith repositioning manoeuvers (CRM) in patients with benign paroxysmal positional vertigo (BPPV). Georgian Medical News, (148-149), 40-44. Abstract retrieved March 6, 2008 from PubMed database.
ORIGINAL EFFECTIVE DATE: 12/1/2001
MOST RECENT REVIEW DATE: 4/10/2008
ID_BA
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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