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Local Coverage Determination (LCD)

Vestibular Function Testing

L34537

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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
L34537
Original ICD-9 LCD ID
Not Applicable
LCD Title
Vestibular Function Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34537
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/09/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/22/2016
Notice Period End Date
02/05/2017

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1861(ll)(3) and (ll)(4)(B) defines Speech-Language Pathology Services and Audiology Services.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.3 Audiology Services and §80.3.1 Definition of Qualified Audiologist

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.2.3 Requesting Additional Documentation During Prepayment and Postpayment review

42 CFR §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).

42 CFR §410.33 Independent diagnostic testing facility

HCFA Ruling 95-1 is binding on providers, contractors, appeal levels, and an Administrative Law Judge. Ruling 95-1 describes limitations on the usage of limitation of liability (SSA, §1879). 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This policy addresses diagnostic testing of the vestibular system. Vestibular tests are tests of function, designed to identify a potential cause of balance problems. Their purpose is to determine if there is a problem with the vestibular portion of the brainstem and inner ear. Studies have documented that in appropriate clinical settings, vestibular tests are more accurate than clinical examination in identifying these disorders. The appropriate clinical setting is described in this policy, including careful evaluation of the patient, rationale for ordering high quality tests, clear communication between the treating physician, consulting physician, and audiologist, interpretation in light of the patient's case, and a plan for use of the results in the patient's care. Diagnostic tests are not payable by Medicare unless directly used in the patient's care.

Vestibular function testing (VFT) is covered for the purpose of determining the appropriate medical or surgical treatment of disorders in the vestibular system. Other causes of balance problems can be found in other systems including the senses of sight and touch, proprioception, muscle movement, and from the integration of sensory input by the cerebellum. Causes of balance problems can also include low blood pressure (BP), including postural hypotension, asymmetrical gait due to pain, poor vision, poorly fitting shoes, lack of concentration on safety in the immediate environment, anxiety, and others.

Vestibular Testing

When a patient presents with complaints of balance problems, a thorough history should be taken, a complete physical examination should be conducted and a thorough review of medications should be completed. These expected medical activities can often elicit a likely cause of the problem. A complete picture of the patient is necessary before testing decisions can be made. The tests that would identify a common cause of balance problems should be conducted first, with progression in testing toward the least common cause of balance problems.

For example, an electrocardiogram (ECG) may show bradycardias or heartblocks. A series of BP checks may show a pattern related to medication intake time. The patient may be taking more (or less) medication than ordered because he/she didn’t understand the dosing instructions.

If the provider sees or suspects a cause that would warrant a referral to a specialist, a referral would be expected. For example, if an ECG showed cardiac rhythm abnormalities, a referral to Cardiology would be expected. Any neurological findings on physical examination could warrant a referral to a neurologist, neurosurgeon, neurotologist, or similar specialist. Since vestibular disorders are common causes of vertigo, imbalance and falling, referral to specialists of these disorders may lead to more rapid diagnosis and most appropriate use of vestibular testing.

Treating Physician / Billing Provider

As noted above, VFTs are covered by Medicare only if they are clinically necessary to diagnose vestibular disorders. A test is clinically necessary if there is (A) appropriate evaluation and justification prior to the test and (B) the results are used to manage the patient. A written order is required from a physician who is treating the beneficiary; that is, the physician who is (A) furnishing a consultation or (B) treating a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. The treating physician has a relationship with the beneficiary prior to the performance of the testing and is treating the beneficiary for a specific medical problem for which the tests are being ordered.

Scope of Practice

Dizziness may support the medical necessity for hearing tests in the initial otolaryngologic evaluation of patients in whom general medical causes (anemia, cardiovascular, metabolic, etc.) have been excluded. However, since dizziness is a vague complaint, a diagnosis of dizziness alone does not qualify for coverage for VFT. There must be sufficient evaluation of the patient that vestibular testing is likely to contribute directly to the patient's therapy. In those instances, full audiometric evaluation can be a critical part of a full vestibular evaluation. The patient's record should clearly document these circumstances.

When the medical conditions requiring medical or surgical treatment are already known by the physician, or are not under consideration, and the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid, the services are statutorily excluded from Medicare coverage whether performed by a physician or nonphysician.

Hearing Testing

Standard hearing tests are not addressed in this policy. However, when a hearing test is ordered as a basis from which to decide to conduct vestibular testing (the provider may suspect a vestibular problem but wants to rule out a pathology other than normal age-related hearing loss), the hearing test will be covered.

Diagnostic audiologic testing (including hearing and balance assessment services) is covered when performed by a physician or a qualified audiologist. An individual with a master's or doctoral degree in audiology and is licensed as such by the relevant State is considered to be a qualified audiologist. In addition to required licensure, audiologists are encouraged to obtain a Certificate of Clinical Competence from the American Speech-Language-Hearing Association (ASHA).

In addition to the above qualification criteria, the following requirements must also be met:

  1. The testing is ordered by a physician to obtain additional information to evaluate the need for or appropriate type of medical or surgical treatment for a hearing deficit or a medical problem; and

  2. The name of the physician ordering the testing is reported on the audiologist’s claim (for example, testing performed by the audiologist to measure a hearing deficit or to identify the factors responsible for the deficit is covered when such services enable the physician to determine whether otologic surgery is indicated).

Basic Audiometry: Adequate testing requires an audiometer (device for presenting sounds to the patient at precisely controlled intensity), a sound-proof environment, a physician/audiologist, and a cooperative patient.
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
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Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
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MAC Meeting Information URLs
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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

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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N/A

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

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements:

Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.

The patient’s record must document a balance problem which required further evaluation to determine the appropriate medical or surgical treatment.

Services are excluded when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for or the appropriate type of a hearing aid. Diagnostic services performed by a qualified audiologist and meeting the above requirements are payable as “other diagnostic tests”. Medicare coverage for these services is determined by the reason the tests were performed, rather than the diagnosis or the patient's condition.

Utilization

It is very rarely necessary to conduct the entire battery of tests. In particular, as discussed in the Coverage Indications, Limitations and/or Medical Necessity section, previous workup, history, and exam will be carefully scrutinized to ensure that exhaustive test batteries are justified and appropriate to the patient’s history and symptoms. It is not necessary to conduct additional tests once the problem and its diagnosis have been determined or identified.

Most of the tests for vestibular function are conducted once per day. Repeat testing is only covered when medically necessary to assess specific medical or surgical treatments. In this instance, medically necessary means, for example, if symptoms are unchanged or a treatment completely resolves symptoms, elaborate repeat testing is not usually medically necessary to confirm this.

Repeat testing on a regular basis, in the absence of the resumption of symptoms, is not warranted. A few conditions may require testing on multiple days due to variably acute symptoms, such as benign positional vertigo which varies with inner ear canal stones.
Sources of Information
N/A
Bibliography

Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology Head and Neck Surg. 2008;139(5 suppl 4):S47-S81.

Desmond AL. Vestibular Function: Evaluation and Treatment. New York, NY: Thieme Medical Publishers, Inc; 2004:65-111.

Goebel JA. Practical Management of the Dizzy Patient. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

Strupp M, Brandt T. Diagnosis and treatment of vertigo and dizziness. Dtsch Arztebl Int. 2008;105(10):173-180.

Vestibular Disorders Association. Vestibular Disorders: An Overview. Accessed on 8/3/2021.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/09/2021 R15

Under CMS National Coverage Policy updated section headings to regulations. Punctuation was corrected throughout the LCD. Under Bibliography changes were made to citations to reflect AMA citation guidelines.
  • Provider Education/Guidance
10/24/2019 R14

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Vestibular Function Testing A56497 article.

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.

 
  • Provider Education/Guidance
05/16/2019 R13

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Vestibular Function Testing A56497 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

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.
  • Provider Education/Guidance
04/18/2019 R12

All coding located in the Coding Information section has been moved into the related Billing and Coding: Vestibular Function Testing A56497 article and removed from the LCD. 

Under CMS National Coverage Policy removed the first paragraph regarding quoted Internet Only Manual (IOM) text. Under Coverage Indications, Limitations and/or Medical Necessity subsection Hearing Testing removed quoted Internet Only Manual (IOM) text from the second paragraph and changed verbiage to read “An individual with a master’s or doctoral degree in audiology and is licensed as such by the relevant State is considered to be a qualified audiologist”. All verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Vestibular Function Testing A56497 article. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD.

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.
  • Provider Education/Guidance
06/28/2018 R11

Under CMS National Coverage Policy deleted the verbiage “NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860 (b) and 42 CFR 426 (Subpart D)). In addition, an administrative law judge may not review a NCD. See section 1869 (f)(1)(A)(l) of the Social Security Act” in the first paragraph. Under Associated Information – Documentation Requirements added the verbiage “Relative Value Units” before the acronym RVU’s and placed parenthesis around the acronym in the last sentence. Formatting, punctuation and typographical errors were corrected and CPT® was inserted throughout the policy where applicable.

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.
  • Provider Education/Guidance
02/26/2018 R10 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
08/03/2017 R9

Under CMS National Coverage added the first paragraph, revised the verbiage for Title XVIII of the Social Security Act, §1862 (a) (7) and deleted the example cited for HCFA Ruling 95-1. The section cited for Independent diagnostic testing facility was corrected to read §410.33. Under Coverage Indications, Limitations and/or Medical Necessity deleted “the” in the second sentence of the second paragraph. Under Treating Physician/Billing Provider deleted “If” in the third sentence and corrected capitalization and punctuation. Under Scope of Practice in the first sentence, the CPT code range was revised to now read 92541-92542 and 92544-92548 and “provides” was corrected to now read “providers”. Under Hearing Testing italicized the second sentence in the second paragraph.  Under Associated Information-Documentation Requirements-Utilization added “In this instance…” to the last sentence in the second paragraph and deleted CPT code 92285 from the fourth paragraph.  Under Associated Information-Documentation Requirements-Utilization-Summary italicized verbiage in the second paragraph and corrected “war” to read “warm”. In the fourth paragraph added verbiage in the first sentence and revised “exam” to read “examination”.  Under Sources of Information and Basis for Decision corrected the following journal citation to now read Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 suppl 4):S47-S81.
  • Provider Education/Guidance
  • Typographical Error
05/13/2017 R8 Under ICD-10 Codes that Support Medical Necessity – added codes H90.0, H90.11, H90.12, H90.A11, H90.A12, H90.71, H90.72.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
02/06/2017 R7 Updated to include all revisions made under Revision 5 as the changes did not hold when this LCD was moved from comment to notice under Revision 6.
  • Provider Education/Guidance
02/06/2017 R6 No comments were received from the provider community; therefore, no revisions were made.
  • Provider Education/Guidance
10/06/2016 R5 Under CMS National Coverage Policy revised the verbiage for Title XVIII of the Social Security Act, §1862(a)(1)(A) to read “allows coverage and payment for only those services that are considered reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. For Title XVIII of the Social Security Act, §§1861(ll)(3) and (ll)(4)(B) revised the verbiage to read “defines Speech-Language Pathology Services and Audiology Services”. 42 CFR §410.327700(b)(3) was removed as this CFR does not exist. For CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.3 and 80.3.1 revised the verbiage to read “defines Audiology Services and a qualified audiologist”. For 42 CFR §410.32 revised the verbiage to read “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)”. For 42 CFR §410.32 revised the verbiage to read “Independent diagnostic testing facility”. Capitalization and punctuation was corrected throughout this section. Under Coverage Indications, Limitations and/or Medical Necessity-Vestibular Testing in the second paragraph defined the acronym Electrocardiography (ECG). Under Associated Information – Documentation Requirements revised the “ICD-9-CM” to “ICD-10” throughout this section. Under Sources of Information and Basis for Decision deleted the verbiage in the first line “Specialists in Neurology, Neurosurgery, Neuro-otolaryngology”. The author’s initial and volume number were added to the first cited reference. Deleted the last sentence “NOTE: Some of the websites used to create this policy may no longer be available”.
  • Provider Education/Guidance
  • Typographical Error
10/01/2016 R4 Under ICD-10 Codes That Support Medical Necessity added H90.A21, H90.A22, H90.A31, and H90.A32. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R3 Under CPT/HCPCS Codes section CPT code 92543 was deleted and CPT codes 92537 and 92538 were added. Under Associated Information section CPT code 92543 may often be billed up to a quantity of 4 units, of the test per session, when four different tests are performed, as described in the CPT text and in CPT Assistant, May 1996 was deleted and CPT code 92537 is intended to report a complete caloric vestibular testing procedure that includes bilateral performance of bithermal irrigation (i.e., one warm and one cool irrigation for each ear). Fewer irrigation procedures require a different method of reporting according to what was done. For three irrigations (e.g., irrigation of both ears using monothermal irrigation of one ear and bithermal irrigation of the contralateral ear), code 92537 and report with modifier 52. Monothermal irrigation (i.e., irrigation of both ears with either cool or war irrigation) is reported once with CPT code 92538. If a single ear is irrigated with a single method of irrigation (cool or warm) code 92538 is reported once with modifier 52, as described in the CPT Insiders View January 2016 was added. These revisions are due to the CPT/HCPCS Annual Update for 2016 and become effective 1/1/16.
  • Revisions Due To CPT/HCPCS Code Changes
10/08/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity subtitle Treating Physician / Billing Provider, second sentence removed the word is and finished the sentence "the results are used to manage the patient.
  • Typographical Error
10/01/2015 R1 Under Sources of Information and Basis for Decision removed two web site address www.ucsf.edu/audio/vestibular and www.militaryaudiology.org/afaa/docs/13 as these web addresses were no longer available regarding Vestibular Function Testing. Added reference Strupp M, Brandt T. Diagnosis and Treatment of Vertigo and Dizziness. Deutsches Arzteblatt International. 2008;105(10):173-80.
  • Provider Education/Guidance
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Associated Documents

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Public Versions
Updated On Effective Dates Status
09/03/2021 09/09/2021 - N/A Currently in Effect You are here
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Keywords

  • Vestibular

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