L28809-LCD

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Local Coverage Determination (LCD) for Computerized Dynamic Posturography (L28809)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28809

LCD Title Computerized Dynamic Posturography

Contractor's Determination Number A92548

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Computerized dynamic posturography (CDP) is a means of assessing a patient’s ability to use vestibular system information. The equipment for dynamic posturography consists of a moveable platform surrounded by a moveable screen that is computer-controlled. Both can move separately or simultaneously. CDP includes three protocols: 1). The Sensory Organization Test (SOT) assesses the patient’s ability to balance using visual, vestibular, and proprioceptive information and to appropriately suppress disruptive visual and/or proprioceptive information under sensory conflict conditions. 2). The Motor Control Test (MCT) measures the ability to reflexively recover from unexpected external provocations. 3). Adaptation Test (ADT) measures the ability to modify automatic reactions when the support surface is irregular or unstable.

Medicare will consider CDP medically reasonable and necessary for any of the following indications:

I. Neurologic disease and disorders: Inherited disorders

• Patients with significant disequilibrium and dysfunction following head trauma, and a complete neurological workup is negative and symptoms persist.

CDP may be considered medically necessary for patients who are being evaluated for balance impairment after trauma. Either brain trauma or damage to the inner ear may result in disequilibrium and impaired postural stability. Posturography may help identify and characterize abnormalities of vestibulo-spinal function when other tests do not.

• Differentiation of peripheral sensory and central nervous system postural control abnormalities.

• Gait or balance disorders in whom neurologic evaluation is insufficient to explain symptoms.

• Identification of early Multiple Sclerosis in patients with balance impairment when the MRI is normal.

II. Peripheral Vestibular Disorders

• Patients with non-localizing vestibular tests (e.g. ENG performed prior to platform testing is normal or does not localize lesion to a specific inner ear) but symptoms of dizziness or disequilibrium persist.

• Differentiation of vestibular, visual, and somatosensory impairments to postural control.

CDP may be considered medically necessary for patients who have symptoms of disequilibrium and conventional tests of vestibular function have not detected an abnormality. Because it is used to test vestibular-oculomotor reflexes primarily mediated by the lateral vermicular canal and/or posterior canals, electronystagmography does not test many of the vestibular receptors, CDP may be helpful when it its important to document whether an abnormality in postural control is present. It may show an abnormality for patients who have dysfunction of the other receptors that are important for balance or may point to non-organic disorders.

• Post aminoglysocoside therapy, chemotherapy, or post –operative inner ear surgery with persistent symptoms or disequilibria.

III. Aging and the elderly, Disequilibrium

• History of one or more falls due to persistent vertigo or dizziness with disequilibrium and normal cardiac testing

• Severe disabling disequilibrium without obvious explanation

• Vertigo or dizziness not responsive to usual medications

• Documentation of age-related changes in balance function (including falls in the elderly)

Aging patients are most prone to falls and injuries related to falls. Many of these patients do not have true vertigo but instead exhibit chronic disequilibrium. CDP may help identify deficits in balance function when the vestibule- oculomotor reflexes are intact, leading to effective intervention.

Posturographic methods that do not satisfy the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Academy of Neurology (AAN) criteria cannot be considered equivalent to those that do comply with the AAO-HNS and AAN guidelines.

As defined by the American Academy of Otolaryngology- Head and Neck Surgery and the American Academy of Neurology, CDP includes:

1. Isolation and quantification of orientation inputs from the visual, vestibular and somatosensory systems.

2. Isolation and quantification of central integrating mechanisms for selecting functionally appropriate orientation sense(s).

3. Isolation and quantification of functionally appropriate movement strategy (s) in a variety of controlled task conditions.

4. Isolation and quantification of motor output mechanisms for generating timely and effective postural movements.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)

013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

047X Audiology - General Classification

CPT/HCPCS Codes

92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY

ICD-9 Codes that Support Medical Necessity

334.0 - 334.9 FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

386.00 - 386.9 MÉNIÈRE'S DISEASE, UNSPECIFIED - UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS

438.84 ATAXIA

438.85 VERTIGO

719.7 DIFFICULTY IN WALKING

780.4 DIZZINESS AND GIDDINESS

781.2 ABNORMALITY OF GAIT

781.3 LACK OF COORDINATION

850.11 CONCUSSION WITH LOSS OF CONSCIOUSNESS OF 30 MINUTES OR LESS

850.12 CONCUSSION WITH LOSS OF CONSCIOUSNESS FROM 31 TO 59 MINUTES

850.2 CONCUSSION WITH MODERATE LOSS OF CONSCIOUSNESS

850.3 CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS AND RETURN TO PRE- EXISTING CONSCIOUS LEVEL

850.4 CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL

850.5 CONCUSSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION

850.9 CONCUSSION UNSPECIFIED

951.5 INJURY TO ACOUSTIC NERVE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Documentation should include copies of the graphical summaries obtained during CDP testing and the physician’s interpretation.

Medical necessity for providing the service must be clearly documented in the patient’s records and submitted upon request for review.

In addition the medical record should include the following:

1. When CDP is performed for patients who have a history of falls due to persistent vertigo or dizziness and is not related to a cardiac condition, the medical record must clearly document the falls, and include information about recent evaluation by treating physician. This may include EKG, laboratory studies, holter monitor, MRI, EEG, EMG or other medical documentation.

2. When CDP is performed for patients with significant disequilibrium and dysfunction following head trauma, the medical record must clearly reflect the nature of the trauma and the date that the trauma occurred.

3. It should be documented that this test is being done as part of a provider initiated workup for chronic unexplained disequilibrium, vertigo or dizziness. It is expected that this test would be performed as part of an organized balance and/or fall prevention program.

4. When CDP is performed for patients with non-localizing vestibular function tests, but symptoms of dizziness or disequilibrum persist the medical record must clearly reflect the vestibular study was performed.

5. The medical record should also document the patient’s general cognitive status. That is, the patient must be able to understand and follow commands, in order to learn appropriate habituation and compensatory strategies. It is not expected that patients with severe or advanced dementia would undergo CDP testing.

Appendices

Utilization Guidelines It is expected that these services would not be performed more than once for a clinical indication. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Badke, M.B., Miedaner, J.A., Shea, T.A., Grove, C.R., Pyle, G.M. (2005). Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap. Annals of Otology Rhinology Laryngology. 114:48-54. This source was used to support indications.

Black, F.O. (2001). Clinical status of computerized dynamic posturograpy in neurotology. Current opinion in Otolaryngology & Head and Neck Surgey. 9: 314-318. This source was used to support indications and limitations.

Definition of Computerized Dynamic Posturography as defined by the American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Neurology: http://www.onbalance.com/program/role/cdp/defined.aspx

Hain, T. C., Oto-Neurologist, Neurophysiologist, statement on Posturography:http://www.dizziness-and- balance.com/testing/posturography.html.

Perez, N., Martin, E., Garcia-Tapia, R. (2003). Relating the severity of vertigo to the degree of handicap by measuring vestibular impairment. Otolaryngology Head neck Surgery. 128:372-381. This source was used to support indications.

Stewart, M.G., Chen, A Y., Wyatt, R., Favrot, S, Beinart, S., Coker, N.J., Jenkins, H.A. (1999). Cost effectiveness of the diagnostic evaluation of vertigo. Laryngoscope. 109: 600-605. This source was used to support indications.

Statement from the American Academy of Otolaryngology Head and neck Surgery on Computerized Dynamic Posturography:http://www.entlink.net/practice/rules/dynamic_posturography.cfm.

Web Encyclopedia defining Posturography:http://en.wikipedia.org/wiki/Posturography. Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28809) replaces LCD L21633 as the policy in notice. This document (L28809) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0470 was changed 8/1/2010 - The description for Revenue code 0471 was changed 8/1/2010 - The description for Revenue code 0472 was changed 8/1/2010 - The description for Revenue code 0479 was changed

Reason for Change