LCD/NCD Portal

L29123 COMPUTERIZED DYNAMIC POSTUROGRAPHY

 

 

02/02/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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

• Neurologic disease and disorders: Inherited disorders

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

o CDP may be considered medically necessary for patients who are being evaluated for balance impairment after trauma.

o Either brain trauma or damage to the inner ear may result in disequilibrium and impaired postural stability.

o 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 which neurologic evaluation is insufficient to explain symptoms.

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

• Peripheral Vestibular Disorders

o 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.

o 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 is 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.

• Aging and the elderly, Disequilibrium

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

o Severe disabling disequilibrium without obvious explanation

o Vertigo or dizziness not responsive to usual medications

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

o Aging patients are most prone to falls and injuries related to falls.

o Many of these patients do not have true vertigo but instead exhibit chronic disequilibrium.

o CDP may help identify deficits in balance function when the vestibule-oculomotor reflexes are intact, leading to effective intervention.

o 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.

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

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

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

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

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

 

 

CPT/HCPCS Codes

 

92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY

 

 

ICD-9 Codes that Support Medical Necessity

 

334.0 FRIEDREICH'S ATAXIA

334.1 HEREDITARY SPASTIC PARAPLEGIA

334.2 PRIMARY CEREBELLAR DEGENERATION

334.3 OTHER CEREBELLAR ATAXIA

334.4 CEREBELLAR ATAXIA IN DISEASES CLASSIFIED ELSEWHERE

334.8 OTHER SPINOCEREBELLAR DISEASES

334.9 SPINOCEREBELLAR DISEASE UNSPECIFIED

386.00 MÉNIÈRE'S DISEASE, UNSPECIFIED

386.01 ACTIVE MÉNIÈRE'S DISEASE, COCHLEOVESTIBULAR

386.02 ACTIVE MÉNIÈRE'S DISEASE, COCHLEAR

386.03 ACTIVE MÉNIÈRE'S DISEASE, VESTIBULAR

386.04 INACTIVE MÉNIÈRE'S DISEASE

386.10 PERIPHERAL VERTIGO UNSPECIFIED

386.11 BENIGN PAROXYSMAL POSITIONAL VERTIGO

386.12 VESTIBULAR NEURONITIS

386.19 OTHER PERIPHERAL VERTIGO

386.2 VERTIGO OF CENTRAL ORIGIN

386.30 LABYRINTHITIS UNSPECIFIED

386.31 SEROUS LABYRINTHITIS

386.32 CIRCUMSCRIBED LABYRINTHITIS

386.33 SUPPURATIVE LABYRINTHITIS

386.34 TOXIC LABYRINTHITIS

386.35 VIRAL LABYRINTHITIS

386.40 LABYRINTHINE FISTULA UNSPECIFIED

386.41 ROUND WINDOW FISTULA

386.42 OVAL WINDOW FISTULA

386.43 SEMICIRCULAR CANAL FISTULA

386.48 LABYRINTHINE FISTULA OF COMBINED SITES

386.50 LABYRINTHINE DYSFUNCTION UNSPECIFIED

386.51 HYPERACTIVE LABYRINTH UNILATERAL

386.52 HYPERACTIVE LABYRINTH BILATERAL

386.53 HYPOACTIVE LABYRINTH UNILATERAL

386.54 HYPOACTIVE LABYRINTH BILATERAL

386.55 LOSS OF LABYRINTHINE REACTIVITY UNILATERAL

386.56 LOSS OF LABYRINTHINE REACTIVITY BILATERAL

386.58 OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION

386.8 OTHER DISORDERS OF LABYRINTH

386.9 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

850.3 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

 

 

Documentation 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:

o 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.

o 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.

o 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.

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

o 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.

 

 

Treatment Logic

 

• 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:

o 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.

o The Motor Control Test (MCT) measures the ability to reflexively recover from unexpected external provocations.

o Adaptation Test (ADT) measures the ability to modify automatic reactions when the support surface is irregular or unstable.

 

 

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 posturography in neurotology. Current opinion in Otolaryngology & Head and Neck Surgery. 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

 

FCSO LCD 29123, Computerized Dynamic Posturography, 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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.

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD COMPUTERIZED DYNAMIC POSTUROGRAPHY