Local Coverage Determination (LCD)

Visual Electrophysiology Testing

L37015

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37015
Original ICD-9 LCD ID
Not Applicable
LCD Title
Visual Electrophysiology Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL37015
Original Effective Date
For services performed on or after 07/17/2017
Revision Effective Date
For services performed on or after 10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
06/01/2017
Notice Period End Date
07/16/2017

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

Review completed with no change in coverage.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Code of Federal Regulations 42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician or other treating practitioner acting within the scope of his or her license and Medicare requirements who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or another qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

VEP/VER - The visual evoked response (VER) and visual evoked potential (VEP) evaluate the visual nervous system pathways from the eyes to the occipital cortex of the brain. By measuring the function of the entire visual pathway, it helps to separate eye disease from central nervous system defects. VER/VEP involves stimulation of the retina and optic nerve with a shifting checkerboard pattern or flash method. This external visual stimulus causes measurable electrical activity in neurons within the visual pathways. The VER is recorded by electroencephalography electrodes located over the occiput producing a characteristic waveform. Abnormalities may be seen in a variety of pathologic processes involving the optic nerve and its radiations. Pattern-shift VER is a highly sensitive means of documenting lesions in the visual system.

ERG - The full field electroretinogram (ERG) is used to detect loss of retinal function or distinguish between retinal and optic nerve lesions. ERG measures the electrical activity generated by neural and non-neuronal cells in the retina in response to a light stimulus. ERGs are usually obtained using electrodes embedded in a corneal contact lens, or a thin wire inside the lower eyelid, which measure a summation of retinal electrical activity at the corneal surface. The International Society for Clinical Electrophysiology of Vision (ISCEV) introduced minimum standards for the ERG in 1989. The ERG helps to distinguish retinal degeneration and dystrophies. Multi-focal electroretinography (mfERG) is a higher resolution form of ERG, enabling assessment of ERG activity in small areas of the retina. Pattern ERG (PERG) to assess retinal ganglion cell (RGC) function in glaucoma is being investigated.

Indications of Coverage
Visual Evoked Potentials or Responses (VEPs/VERs)

  1. Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive
  2. Evaluate diseases of the optic nerve, such as:
    1. Optic neuritis
    2. Ischemic optic neuropathy
    3. Toxic amblyopias
    4. Nutritional amblyopias
    5. Neoplasms compressing the anterior visual pathways
    6. Optic nerve injury or atrophy
    7. Malingering/functional vision loss (to rule out)
  3. Monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies)

Electroretinography (ERG)

  1. To diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions:
    1. Toxic retinopathies, including those caused by intraocular metallic foreign bodies and Vigabatrin
    2. Diabetic retinopathy
    3. Ischemic retinopathies including central retinal vein occlusion (CRVO), branch vein occlusion (BVO), and sickle cell retinopathy
    4. Autoimmune retinopathies such as Cancer Associated Retinopathy (CAR), Melanoma Associated Retinopathy (MAR), and Acute Zonal Occult Outer Retinopathy (AZOOR)
    5. Retinal detachment
    6. Assessment of retinal function after trauma, especially in vitreous hemorrhage, dense cataracts, and other conditions where the fundus cannot be visualized photoreceptors; absent b-wave indicates abnormality in the bipolar cell region.
    7. Retinitis pigmentosa and related hereditary degenerations
    8. Retinitis punctata albescens
    9. Leber's congenital amaurosis
    10. Choroideremia
    11. Gyrate atrophy of the retina and choroid
    12. Goldmann-Favre syndrome
    13. Congenital stationary night blindness
    14. X-linked juvenile retinoschisis
    15. Achromatopsia
    16. Cone dystrophy
    17. Disorders mimicking retinitis pigmentosa
    18. Usher Syndrome
  2. To detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity (mfERG) per the American Academy of Ophthalmology (AAO) guidelines (10).


VEP/ERG in Glaucoma (Non-Covered)
A 2011 report by the AAO on “Assessment of Visual Function in Glaucoma” noted that while VEP and ERG, as objective measures of visual function, provided testing free of patient input, issues prevent their adoption for glaucoma management. It concluded that advances in technology have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time and that further research on an objective measure of visual function is needed.

Since then several studies have investigated the use of VEP and ERG technology to differentiate between normal healthy eyes and eyes with early to advanced visual field loss resulting from glaucoma. The authors indicated that VEP and ERG may allow earlier diagnosis of glaucoma. However, without larger studies, WPS GHA and the AAO’s 2011 report both agree that these technologies have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time. This was also the conclusion of a 2013 study which prospectively monitored progressive changes of RGC function in early glaucoma using PERG. The authors concluded that further follow-up is required to determine whether PERG losses are predictors of future visual field loss.

Neither of the 2015 AAO Preferred Practice Guidelines, “Primary Open-Angle Glaucoma Suspect” or “Primary Open-Angle Glaucoma,” mention VEP or ERG as diagnostic tools. Also, the UpToDate® review on “Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis,” likewise omits reference to either test.

There remain no verified guidelines for normal vs abnormal that would be easily applicable to an individual patient. WPS GHA, therefore, considers the use of VEP or ERG for either glaucoma diagnosis or management investigational.

Limitations
Testing shall be performed by physicians who have evidence of knowledge, training, and expertise to perform and interpret these tests. This training and expertise must have been acquired within the framework of an accredited school, residency, or fellowship program.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Coverage Indications, Limitations, and/or Medical Necessity") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the MAC upon request.

Sources of Information
N/A
Bibliography

American Academy of Ophthalmology (AAO). (2015). Glaucoma Panel. Primary open-angle glaucoma suspect. Preferred practice pattern. San Francisco, CA: AAO.

Banitt MR, Ventura LM, Feuer WJ, et al. Progressive loss of retinal ganglion cell function precedes structural loss by several years in glaucoma suspects. Invest Ophthalmol Vis Sci. 2013;54(3):2346-52.

Horn FK, Kaltwasser C, Jünemann AG, Kremers J, Tornow RP. 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.

Jacobs DS. Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis.
UpToDate® Inc. 2016.

Jafarzadehpour E, Radinmehr F, Pakravan M, Mirzajani A, Yazdani S. Pattern electroretinography in glaucoma suspects and early primary open angle glaucoma. J Ophthalmic Vis Res. 2013; 8(3):199-206.

Jampel HD, Singh K, Lin SC, et al. Assessment of visual function in glaucoma: A report by the American Academy of Ophthalmology. Ophthalmology. 2011; 118(5):986-1002.

Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF. American academy of ophthalmology statement: Recommendations on screening for chloroquine and hydroxycholoquine retinopathy. Ophthalmology. 2016; 123(6):1386-1394.

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.

Ventura LM, Golubev I, Feuer WJ, Porciatti V. Pattern electroretinogram progression in glaucoma suspects. J Glaucoma. 2013; 22:219–225.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2023 R9

Posted 09/28/2023: Biannual Review completed 08/14/2023 with no change in coverage.

  • Other ((review))
05/26/2022 R8

Posted 05/26/2022: Review completed 04/12/2022. Minor typographical errors corrected throughout the LCD. Moved references listed under Sources of Information to the Bibliography section and made corrections to reflect AMA formatting guidelines. 

  • Other (review)
11/01/2019 R7

05/28/2020 Review performed 05/01/2020

  • Other ((review))
11/01/2019 R6

Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from this LCD and placed in the Billing and Coding Article related to this LCD. Consistent with Change Request 10901, if any language from IOMs and/or regulations was present in the LCD, it has been removed and the applicable manual/regulation has been referenced.

  • Revisions Due To Code Removal
01/01/2019 R5

01/01/2019 CPT/HCPCS code updates: deleted code 92275 and added codes 92273 and 92274.

  • Revisions Due To CPT/HCPCS Code Changes
06/01/2018 R4

06/01/2018 Annual review done 05/02/2018. Typographical errors corrected. No change in coverage.

  • Other (Annual Review)
01/01/2018 R3

01/01/2018 CPT/HCPCS code updates: description change to Group 1 code 95930.

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R2

10/01/2017 ICD-10 code updates: Description changes to Group 1: S04.031A, S04.031D, S04.031S, S04.032A, S04.032D, S04.032S, S04.041A, S04.041D, S04.041S, S04.042A, S04.042D, and S04.042S; deleted codes from Group 1 H54.0, H54.11, H54.12, H54.2, H54.41, H54.42, H54.51, and H54.52; and added codes to Group 1 H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.511A, H54.512A, H54.52A1, and H54.52A2.

  • Revisions Due To ICD-10-CM Code Changes
08/01/2017 R1

08/01/2017 Added the following diagnosis codes to Group 1 for 95930 visual evoked potential (VEP) testing: H47.521, H47.522, H53.011, H53.012, H53.013, H53.021, H53.022, H53.023, H53.031, H53.032, and H53.033. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/19/2023 10/01/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

Read the LCD Disclaimer