Visual and Auditory Evoked Potentials

BlueCross BlueShield of Tennessee Medical Policy Manual

DESCRIPTION

Sensory evoked potentials (SEP) are electrical waves that are generated by the response of sensory neurons to stimuli. Changes in the electrical waves are averaged by a computer and then interpreted by a physician. Computer averaged SEPs can be used to assist the diagnosis of certain neuropathologic states or to provide information for treatment management. Two methodologies of monitoring are visual evoked potential (VEP) and auditory evoked potential (AEP).

Visual evoked potential is used to track visual signals from the retina to the occipital cortex light flashes. It has been used for surgery on lesions near the optic chiasm. VEP can be difficult to interpret due to their sensitivity to anesthesia, temperature and blood pressure.

Auditory evoked potential is also called auditory brainstem response (ABR). It is an electrophysiologic measure of auditory function that utilizes responses produced by the auditory nerve and the brainstem and helps differentiate sensory from neural hearing loss. The response is the waveform averaged over many auditory clicks. Auditory evoked potentials may be used for screening purposes in very young children.

POLICY

Visual and auditory evoked potential recordings are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.

MEDICAL APPROPRIATENESS

Visual and auditory evoked potential recordings are considered medically appropriate if ANY ONE of the following criteria are met:
- Visual evoked potentials (VEP) for ANY ONE of the following:
- - To diagnose and monitor the course of multiple sclerosis (MS). This includes recordings made in the acute phase to disclose the presence of active demyelinating plaques. This also includes recording in the chronic phase to disclose the presence of subclinical plaques.
  - To localize of the basis for visual field defects which occur in the absence of structural lesions, acquired metabolic disease or infectious disease.
- Auditory evoked potentials (AEP) for ANY ONE of the following:
- - To evaluate brainstem function in acquired metabolic disorders, e.g., hypoxic encephalopathy.
  - To use as a second line test to disclose the presence of brainstem tumor if MRI or CT does not reveal a tumor or lesion to be present as indicated by clinical examination. Also to disclose the presence of a brainstem tumor if MRI or CT is not available.
  - To diagnose and monitor the course of demyelinating or degenerative diseases of the brainstem (e.g., MS, central pontine myelinolysis and olivopontocerebellar degeneration).
  - To diagnose the presence of lesions in the auditory system external to the brainstem (e.g., acoustic neuromas).
  - To assess recovery of brainstem function after removal of space occupying lesions compressing the brainstem.
  - To supplement the EEG in evaluating the irreversibility of coma or brain death.
  - To measure the type and extent of hearing impairment or determine the degree of neural maturation in neonates, infants, and children less than 5 years of age; applies to screening for hearing impairment in children less than 5 years of age. (Age listings are intended as a guideline for members who have no other developmental or physical impairment.)

IMPORTANT REMINDERS

Any specific products referenced in this policy are just examples and are intended for illustrative purposes 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. These examples are contained in the parenthetical e.g. statement.

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.

ADDITIONAL INFORMATION

There is a lack of published studies to validate the use of visual and auditory evoked potentials for other indications.

SOURCES

American Academy of Neurology. (2005, October) Practice parameter: Evaluation of the child with global development delay. Retrieved February 1, 2012 from http://www.neurology.org/content/60/3/367.full.pdf.

American Academy of Neurology. (2008, August) Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in patients with suspected multiple sclerosis (an evidence-based review). Retrieved February 1, 2012 from http://www.neurology.org/cgi/reprint/54/9/1720.pdf.

American Clinical Neurophysiology Society. (2006, February). Guideline 9a: Guidelines on evoked potentials. Retrieved February 1, 2012 from http://www.acns.org/pdfs/ACFDFD0.pdf.

American Clinical Neurophysiology Society. Guideline 9b: Guidelines on visual evoked potentials. Journal of Clinical Neurophysiology, 23 (2) 138-156.

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2005). Evaluation of hearing impairment- Archived. (9.01.02). January 23, 2012 from BlueWeb. (6 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2011). Intra-operative neurophysiologic monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) (7.01.58). Retrieved January 23, 2012 from BlueWeb. (12 articles and/or guidelines reviewed)

Complete Guide to Medicare Coverage Issues [Computer software]. (2011, November). Evoked response tests (NCD 160.10, p. 2-81). Ingenix.

Odom, J., Bach, M., Brigell, M., Holder, G., McCulloch, D., Tormene, A., et al. (2010). ISCEV standard for clinical visual evoked potentials (2009 update). Documenta Ophthalmologica. Advances in Ophthamology, 120 (1), 111-119.

U. S. Food and Drug Administration. (2002, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K021895. Retrieved April 20, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf2/K021895.pdf.

U. S. Food and Drug Administration. (2005, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K043491. Retrieved April 20, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf4/K043491.pdf.

Walsh, P. Kane, N., & Butler, S. (2005). The clinical role of evoked potentials. Journal of Neurology, Neurosurgery, Psychiatry. 2005 (7), 16-22.

ORIGINAL EFFECTIVE DATE: 7/1982

MOST RECENT REVIEW DATE: 3/8/2012

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.

This document has been classified as public information.