CurrentAetnaPolicy 0181

Evoked Potential Studies

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Defines medical necessity, investigational exclusions, and applicable CPT/HCPCS/ICD-10 codes for various evoked potential studies (SEPs/DSEPs, VEPs, BAER/ABR, cVEMP, VEMP, otoacoustic emissions, motor evoked potentials) as applied by Aetna.

Policy Summary

PayerAetna

PolicyEvoked Potential Studies

Policy CodePolicy 0181

Change TypeNo material change

Effective Date

Last ReviewOct 25, 2023

Next Review Date

Key ActionDocument specific indication that meets one of the listed medically necessary criteria when ordering SEPs/DSEPs.

SourceLink

POLICY UPDATE CHANGES

There are no material clinical or coverage changes in this update; has_material_change=false in the brief.

9Medically necessary SEP indications listed

4Medically necessary VEP/BAER/cVEMP indications listed

31Experimental/investigational procedures listed

3CPT codes not covered (motor evoked)

3CPT codes not covered (VEMP)

5ICD-10 codes referenced

Coverage Summary

This policy addresses clinical coverage for a range of evoked potential modalities including somatosensory/dermatosensory evoked potentials (SEPs/SSEPs/DSEPs), visual evoked potentials (VEPs), brainstem auditory/brainstem auditory evoked response (BAER/ABR, including BAER/ABR limited and comprehensive), vestibular evoked myogenic potentials (cVEMP, oVEMP, VEMP), evoked otoacoustic emissions (OAE), and motor evoked potentials (MEP). The overall coverage stance is mixed: specific indications are listed as medically necessary, while many other uses are considered experimental/investigational or not covered. For intraoperative monitoring indications, this policy refers to the separate intraoperative neurophysiological monitoring policy CPB 0697.

Thresholds / Cut-offs

Acute anoxic encephalopathy timingwithin 3 days of the anoxic event

Pediatric BAER screening ageinfants and children under 3 years of age (limited tests for screening)

VEP member agemembers > 3 months of age for listed ICD-10 coverage

oVEMP unilateral decrement cut-off>= 15.2 % (Valko 2016)

oVEMP bilateral decrement cut-off>= 20.4 % (Valko 2016)

RoVEMP cut-off>= 14.3 % versus neuromuscular controls (De Meel 2020)

RoVEMP mean decrementMean 28.4% ± 32.2 in MG patients (De Meel 2020)

ECochG SP/AP cut-off> 0.4 (diagnostic benefit maximized when SP/AP > 0.4) (Xu 2019)

VEP rate of change+1.951 ms/year (>=3 months interval, no optic neuritis) (Ringelstein 2020)

Medical-Necessity Criteria

Somatosensory evoked potentials (SEPs, SSEPs) - Medically Necessary

Considered medically necessary for any of the following indications:

To assess any decline which may warrant emergent surgery in unconscious spinal cord injury persons who show specific structural damage to the somatosensory system, and who are candidates for emergency spinal cord surgery.

To evaluate acute anoxic encephalopathy (within 3 days of the anoxic event).within 3 days

To evaluate persons with suspected brain death.

To identify clinically silent brain lesions in multiple sclerosis suspects to establish diagnosis where MS is suspected due to suggestive neurologic symptoms plus one or more other objective findings (brain plaques on MRI, clinical lesions by history and physical exam, and/or positive CSF determined by oligoclonal bands by isoelectric focusing different from serum, or increased IgG index).

To localize the cause of a central nervous system deficit seen on exam but not explained by lesions seen on CT or MRI.

To manage persons with spinocerebellar degeneration (e.g., Friedreich's ataxia, olivopontocerebellar degeneration).

Unexplained myelopathy.

For intraoperative SSEPs under certain conditions (see CPB 0697 - Intraoperative Neurophysiological Monitoring).

SEPs / DSEPs - Experimental and Investigational

Considered experimental and investigational for all other indications because effectiveness not established.

SEPs monitoring during trigger point injection for management of low back pain.

SEPs for radiculopathies and peripheral nerve lesions where standard nerve conduction velocity studies are diagnostic.

SEPs for diagnosis of carpal tunnel syndrome/ulnar nerve entrapment.

SEPs in conscious persons with severe spinal cord or head injuries.

SEPs in diagnosis of cervical spondylitic myeloradiculopathy.

SEPs in diagnosis of thoracic outlet syndrome.

SEPs in diagnosis or management of acquired metabolic disorders (e.g., lead toxicity, B12 deficiency).

SEPs in diagnosis or management of amyotrophic lateral sclerosis (ALS).

Short-latency SSEP study for evaluation of movement disorders.

Pre-operative SSEP of bilateral tibial somatosensory pathways prior to scoliosis surgery.

Evoked potential studies for Kennedy's syndrome/disease.

Other non-listed indications not established.

Visual Evoked Potentials (VEPs) - Medically Necessary

Considered medically necessary for any of the following indications:

To diagnose and monitor multiple sclerosis (acute or chronic phases).

To evaluate signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons).

To identify persons at increased risk for developing clinically definite multiple sclerosis (CDMS).

To localize the cause of a visual field defect not explained by lesions seen on CT or MRI, metabolic disorders, or infectious diseases.

Not recommended: Standard or automated VEPs are considered experimental and investigational for routine screening of infants and other persons.

VEPs - Experimental and Investigational

VEPs are considered experimental and investigational for other indications not listed above.

VEPs for detecting amnestic mild cognitive impairment.

VEPs for evaluation and monitoring of birdshot chorioretinopathy.

Visual evoked potential for evaluation of neuromyelitis optica spectrum disorder.

VEPs for syringomyelia, syringobulbia, vigabatrin-associated retinal toxicity, Plaquenil (hydroxychloroquine) toxicity screening, prognostic tests in neonates with perinatal asphyxia and hypoxic-ischemic encephalopathy.

Brain Stem Auditory Evoked Response (BAER/ABR) - Medically Necessary

Considered medically necessary for any of the following:

For intraoperative monitoring (see CPB 0697 - Intraoperative Neurophysiological Monitoring).

To assess brain death or profound metabolic coma in selected cases where diagnosis or outcome is unclear from standard tests (e.g., EEG).

To assess recovery of brainstem function after surgical removal of lesion compressing brainstem.

To diagnose and monitor demyelinating and degenerative diseases affecting brain stem (e.g., central pontine myelinolysis, OPC degeneration).

To diagnose post-meningitic deafness in children.

To diagnose suspected acoustic neuroma.

To evaluate infants and children with suspected hearing loss not effectively measured/monitored through audiometry.

To localize cause of a CNS deficit seen on exam but not explained by CT or MRI.

To screen infants and children under 3 years of age for hearing loss (limited auditory evoked potentials or limited OAE only; comprehensive testing only if indicated after fail).members < 3 yrs

BAER/ABR - Experimental and Investigational

BAERs are considered experimental and investigational for all other indications not listed above.

BAERs as a test to identify persons at increased risk for developing clinically definite multiple sclerosis (CDMS).

BAERs for syringomyelia and syringobulbia.

Other non-listed indications.

Cervical Vestibular Evoked Myogenic Potential (cVEMP) - Medically Necessary

Considered medically necessary when specific preconditions met:

Evaluation of individuals with vertigo for semicircular canal dehiscence syndrome (SCDS).

Requires prior comprehensive evaluation

A comprehensive evaluation (history, physical, audiometry, electronystagmography or videonystagmography, electrocochleography, brainstem audiometry) has been performed and results are inconclusive.

cVEMP / VEMP / oVEMP - Experimental and Investigational

Considered experimental and investigational for other specified uses:

cVEMP for evaluation of vestibular function specifically related to the saccule/utricle.

cVEMP for diagnosis of benign paroxysmal positional vertigo and vestibular neuritis.

oVEMP for diagnosis of benign paroxysmal positioning vertigo, myasthenia gravis, or vestibular neuritis.

oVEMP for evaluation of vestibular function specifically related to the saccule/utricle.

VEMP for diagnosis of Meniere's disease or delayed endolymphatic hydrops; differentiation of Meniere disease from vestibular migraine.

Evoked Otoacoustic Emissions (OAE) - Medically Necessary (Screening)

Screening/OAE coverage rules:

For purposes of screening (including neonatal screening), only limited auditory evoked potentials or limited evoked otoacoustic emissions (OAE) are considered medically necessary.

Neonates, infants and children under 3 years who fail screening are referred for comprehensive auditory evoked response testing or comprehensive OAE.members < 3 yrs

Evoked OAE is medically necessary to screen children ≤3 years who did not have initial neonatal screening and/or cannot be effectively measured or monitored through audiometry.≤3 years

Routine evoked OAE screening at a well-child visit is not medically necessary for children ≤3 years who have passed the newborn hearing screen unless risk factors, speech/auditory impairment, or abnormal middle ear status are present.≤3 years

Motor Evoked Potentials (non-intraoperative) - Not Covered / Experimental

Motor evoked potentials (other than intraoperative with SSEPs) are not covered/considered experimental for indications listed:

Central motor evoked potential studies (CPT 95928, 95929, 95939) are not covered for listed indications.

Not covered for evaluation of Wilson's disease (E83.01).

Codes Not Covered (motor evoked potentials)

CPT and ICD-10 codes explicitly listed as not covered for indications in the clinical policy bulletin (CPB):

CPT codes not covered for indications listed in the CPB:

95928 — Central motor evoked potential study (transcranial motor stimulation); upper limbs.
95929 — Central motor evoked potential study (transcranial motor stimulation); lower limbs.
95939 — Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.

ICD-10 codes not covered for indications listed in the CPB:

E83.01 — Wilson's disease.

Codes Not Covered (VEMP)

Vestibular evoked myogenic potentials CPT/ICD-10 codes listed as not covered for indications in the CPB:

CPT codes not covered for indications listed in the CPB:

92517 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP).
92518 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP).
92519 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP).

ICD-10 codes not covered for indications listed in the CPB:

G43.801 - G43.819 — Other migraine [vestibular migraine].
H81.01 - H81.09 — Meniere's disease.
H81.10 - H81.13 — Benign paroxysmal vertigo.
H81.20 - H81.23 — Vestibular neuronitis.

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Other ICD-10 codes referenced (screening exam only for members < 3 yrs.)

ICD-10 codes listed in this part as related to screening or examination contexts:

F80.0 - F80.9 — Specific developmental disorders of speech and language.

R94.120 - R94.128 — Abnormal results of function studies of ear and other special senses.

Z01.110 — Encounter for hearing examination following failed hearing screening.

Z01.118 — Encounter for examination of ears and hearing with other abnormal findings.

Z00.121 - Z00.129 — Encounter for routine child health examination with/without abnormal findings.

Documentation Requirements

To qualify for coverage, medical necessity criteria and documentation must be present in the medical record:

All medical necessity criteria must be clearly documented in the member's medical record and made available upon request.

Medical record must contain documentation that fully supports the medical necessity for evoked potential studies, including relevant medical history, physical exam, anatomic location of planned surgical procedure, rationale for location and modalities to be monitored, and results of pertinent diagnostic tests or procedures.

For BAERs, the medical record should document the otologic exam describing both ear canals and tympanic membranes, as well as a gross hearing assessment; include results of air and bone pure tone audiogram and speech audiometry.

The physician’s evoked potential report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.

Baseline testing prior to intraoperative neuromonitoring requires contemporaneous interpretation prior to the surgical procedure; results of testing of multiple leads for signal strength, clarity, amplitude, etc., should be documented.

Operational billing guidance regarding baseline vs intraoperative reporting: Time spent performing or interpreting baseline electrophysiologic studies prior to surgery should not be counted as intraoperative monitoring but represents separately reportable procedures; testing performed during surgery does not qualify as baseline testing and is not a separately reportable procedure.

Coding

Somatosensory evoked potentials (covered if criteria met)CPT|ICD-10Covered

95925	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs.
95926	in lower limbs.
95927	in the trunk or head.
95938	in upper and lower limbs.
G11.1	Early-onset cerebellar ataxia [Friedreich's ataxia].
G23.8	Other specified degenerative diseases of basal ganglia [OPC degeneration].
G35	Multiple sclerosis [with clinically silent lesions].
G36.0 - G37.9	Other demyelinating diseases of central nervous system.
G93.1	Anoxic brain damage, not elsewhere classified.
G93.82	Brain death.

1–10 of 11

1/2

Somatosensory evoked potentials (ICD-10 not covered examples)ICD-10Not Covered

E53.8	Deficiency of other specified B group vitamins [diagnosis and management of acquired metabolic disorders].
F43.10 - F43.12	Posttraumatic stress disorder.
E70.0 - E89.89	Metabolic disorders [diagnosis and management of acquired metabolic disorders].
F90.0 - F90.9	Attention-deficit hyperactivity disorders.
G12.21	Amyotrophic lateral sclerosis.
G12.8 - G12.9	Other and unspecified muscular atrophies.
G25.81 - G25.89	Other specified extrapyramidal and movement disorders.
G25.9	Extrapyramidal and movement disorder, unspecified.
G54.0	Brachial plexus disorders [thoracic outlet syndrome].
G56.00 - G59	Mononeuropathies of upper and lower limbs [radiculopathies, peripheral nerve lesions, carpal tunnel].

1–10 of 14

1/2

Visual evoked potentials (covered if criteria met)CPT|ICD-10Covered

95930	Visual evoked potential (VEP) testing central nervous system, checkerboard or flash.
A39.82	Meningococcal retrobulbar neuritis.
A52.10 - A52.19	Symptomatic neurosyphilis.
A69.20	Lyme disease, unspecified.
G35	Multiple sclerosis.
G36.0 - G37.9	Other demyelinating diseases of central nervous system.
G93.1	Anoxic brain damage, not elsewhere classified.
H47.011 - H47.9	Disorders of the optic nerve and visual pathways.
H53.001 - H53.9	Visual disturbances.
H81.01 - H83.2x9	Disorders of vestibular function.

Visual evoked potentials (not covered / not recommended codes)CPTNot Covered

0333T

Visual evoked potential, screening of visual acuity, automated [not covered for screening].

Brain stem auditory evoked response (BAER) - comprehensive (covered if criteria met)CPT|ICD-10Covered

92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report.
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report.
G93.82	Brain death [for members >3 months of age].
G93.1	Anoxic brain damage.
G35	Multiple sclerosis.
H83.3 - H94.83	Other disorders of ear and hearing loss.
Z01.110	Encounter for hearing examination following failed hearing screening.
Z79.2	Long-term (current) use of antibiotics [damage due to ototoxic drugs].

Brain stem auditory evoked response (limited) (covered if criteria met)CPT|ICD-10Covered

92650	Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis.
92651	Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report.

Evoked otoacoustic emissions (OAE) - CPTs (covered if criteria met)CPTCovered

92558	Evoked otoacoustic emissions, screening (automated analysis).
92587	Evoked otoacoustic emissions; limited (single stimulus level).
92588	Comprehensive or diagnostic evaluation (comparison at multiple levels and frequencies) [not covered for routine neonatal screening].

cVEMP CPTs (covered if criteria met)CPTCovered

92517	Vestibular evoked myogenic potential (VEMP) testing; cervical (cVEMP).
92518	VEMP testing; cervical and ocular (cVEMP and oVEMP).

Motor evoked potentials - CPTs not coveredCPT|ICD-10Not Covered

95928	Central motor evoked potential study; upper limbs.
95929	Central motor evoked potential study; lower limbs.
95939	Central motor evoked potential study; upper and lower limbs.
E83.01	Wilson's disease (ICD-10) - listed as not covered indication.

VEMP CPTs listed as not covered for indications in CPBCPTNot Covered

92517	Vestibular evoked myogenic potential (VEMP) testing; cervical (cVEMP) (listed in not covered section for certain indications).
92518	VEMP; ocular (oVEMP).
92519	VEMP; cervical and ocular.

CPT codes explicitly NOT COVERED (motor evoked potentials)CPTNot Covered

95928	Central motor evoked potential study (transcranial motor stimulation); upper limbs.
95929	Central motor evoked potential study (transcranial motor stimulation); lower limbs.
95939	Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.

CPT codes explicitly NOT COVERED (VEMP)CPTNot Covered

92517	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP).
92518	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP).
92519	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP).

ICD-10 codes listed as NOT COVERED for CPB indications (VEMP/motor evoked contexts)ICD-10Not Covered

E83.01	Wilson's disease.
G43.801 - G43.819	Other migraine [vestibular migraine].
H81.01 - H81.09	Meniere's disease.
H81.10 - H81.13	Benign paroxysmal vertigo.
H81.20 - H81.23	Vestibular neuronitis

ICD-10 codes referenced for screening/exam contexts (members < 3 yrs. or exams)ICD-10

F80.0 - F80.9	Specific developmental disorders of speech and language.
R94.120 - R94.128	Abnormal results of function studies of ear and other special senses.
Z01.110	Encounter for hearing examination following failed hearing screening.
Z01.118	Encounter for examination of ears and hearing with other abnormal findings.
Z00.121 - Z00.129	Encounter for routine child health examination with/without abnormal findings.

Provider Actions & Billing Guidance

Documentation Required

SEPs/DSEPs indication documentation

Document the indication when ordering and in the medical record. For somatosensory evoked potentials (SEPs) / dermatosensory evoked potentials (DSEPs) include the clinical rationale that meets policy-listed indications (e.g., unconscious spinal cord injury with structural somatosensory damage being considered for emergent surgery, acute anoxic encephalopathy within 3 days, suspected brain death, workup for multiple sclerosis, localization of CNS deficit unexplained by CT/MRI, spinocerebellar degeneration, unexplained myelopathy, or intraoperative monitoring per CPB 0697).

Affected codes: 95925, 95926, 95927, 95930

Documentation Required

cVEMP pre-evaluation requirement

Prior to performing cervical VEMP (cVEMP), document that the patient has undergone a comprehensive vestibular evaluation (history, physical exam, audiometry, electronystagmography or videonystagmography, electrocochleography, brainstem audiometry) and that results remain inconclusive for semicircular canal dehiscence syndrome (SCDS).

Affected codes: 92517
Affected codes: 92518

Documentation Required

OAE neonatal screening workflow

For neonatal screening workflows, routine limited otoacoustic emissions (OAE) or limited auditory evoked potentials are the appropriate screening tests. Document screening context (neonatal screen, fail/pass result) and follow-up plan. Comprehensive OAE or comprehensive auditory evoked response testing should only be used after failed screening per policy.

Documentation Required

Use appropriate ICD-10 codes for screening context

When ordering/claiming tests performed in a screening context, ensure the medical record and claim use the appropriate ICD-10 diagnosis codes that justify screening rather than diagnostic evaluation (e.g., newborn screening scenario or specific neonatal hearing screen failure).

Use applicable ICD-10 screening/failure codes as documented in the patient's record

Billing Rule

Do not bill excluded CPT codes for CPB-listed indications

Do not bill the listed CPT codes when the service is excluded by the CPB indications (i.e., when policy labels the use as not medically necessary or experimental for the specific indication). Providers should verify the clinical indication meets policy criteria before billing these CPT codes.

Documentation Required

VEMP as part of diagnostic battery for Meniere disease

Use vestibular evoked myogenic potentials (VEMP) as part of a diagnostic battery when evaluating Meniere disease; document that VEMP was performed as one component of a comprehensive vestibular assessment. Note that policy considers broader use of VEMP experimental/investigational for several vestibular indications, so document the specific clinical question and how VEMP results influenced management.

Use VEMP as part of diagnostic battery for Meniere disease

Documentation Required

oVEMP/RoVEMP utility

Ocular VEMP (oVEMP) and rostral oVEMP (RoVEMP) may provide supportive information in select cases and can aid in the evaluation of myasthenia gravis (MG) in conjunction with other diagnostic testing. Document the specific diagnostic role and how results contributed to diagnosis or management decisions.

oVEMP/RoVEMP may aid MG diagnosis

Documentation Required

cVEMP abnormality predictive note

Report and document any abnormal cVEMP findings and note that certain cVEMP abnormalities have been reported to predict conversion to Meniere disease in longitudinal studies; include how this information affected monitoring or treatment planning.

cVEMP abnormalities may predict conversion to Meniere disease

Documentation Required

Medical record documentation for coverage

Maintain thorough medical record documentation to support coverage: clinical history, indication for the test, prior diagnostic workup and results, rationale for selecting the specific evoked potential study, test report with interpretation, and how the test result informed patient management. Lack of adequate documentation may result in claim denial.

Medical record must contain history, prior testing, rationale, report, and management impact

Documentation Required

BAER-specific documentation

For BAER/ABR testing, document the specific indication consistent with policy (e.g., suspected brain death assessment, intraoperative monitoring per CPB 0697, suspected acoustic neuroma, infants/children under 3 with suspected hearing loss or those who failed screening). Include test parameters, whether limited or comprehensive testing was performed, and referral/follow-up actions.

BAER-specific documentation: indication, parameters, limited vs comprehensive, follow-up plan

Billing Rule

Baseline testing reporting

Baseline (screening) evoked potential tests that are reported as part of a screening program should be billed and reported consistent with policy: limited screening codes only for neonatal/infant screening where indicated, and comprehensive testing only when medically necessary and documented. Do not bill baseline/screening using comprehensive CPT codes when policy restricts screening to limited tests.

Baseline testing reporting — use limited screening codes for neonatal screening; comprehensive tests require documented medical necessity

Documentation Required

Interpretation caution for cooled neonates

Exercise caution when interpreting BAER/evoked potential results in cooled neonates; document the clinical context (therapeutic hypothermia) and note potential effects of cooling on test results.

Interpretation caution for cooled neonates

Documentation Required

VEMP as part of battery

When VEMP is performed, consider and document it as part of a multi-test vestibular battery rather than a standalone definitive test; this supports appropriate clinical use and aligns with policy which limits certain VEMP indications.

VEMP should be documented as part of a diagnostic battery

Evidence, Definitions, and Notes

The Evidence section summarizes systematic reviews, diagnostic accuracy studies, cohort and case-control studies, and guideline statements that inform the policy's recommendations; a full reference list is provided (references 81–145) to support the evidence summaries and conclusions.

Study / Measure	Result / Value
Van Laerhoven et al (2013) pooled VEP performance
VEPs sensitivity 0.90 (0.74-0.97); specificity 0.92 (0.68-0.98)
UpToDate / Wijdicks et al (SSEP prognostic) - post-cardiac arrest
Bilateral absence of N20 within 1-3 days predicts poor outcome with pooled LR 12.0 and false-positive rate 0%
Garfinkle et al (2015) - neonatal SEPs after hypothermia
Bilateral absent N19 PPV 0.36; NPV 0.93 (shows lower PPV with therapeutic hypothermia)
Silverstein et al (2014) - saphenous nerve SSEP intraoperative series
Changes in SSEP in 5 of 41 procedures; 3 patients woke with femoral nerve deficit; none with stable SSEP developed deficits
Fix et al (2015) - FVEP-P2 in MCI/AD
Double-flash 100 ms condition showed higher predictive accuracy vs single-flash for FVEP-P2 latency
Valko et al (2016) - oVEMP for myasthenia gravis
oVEMP sensitivity 89%, specificity 64% (unilateral decrement >=15.2%)
De Meel et al (2020) - RoVEMP for MG
RoVEMP cut-off >=14.3%: sensitivity 67%, specificity 82%; mean decrement 28.4% ± 32.2 in MG patients
Egami et al (2013) - VEMP for Meniere's disease
VEMP sensitivity 50.0%, specificity 48.9%; combined VEMP+caloric sensitivity 65.8%
Xu et al (2019) - ECochG/cVEMP diagnostic accuracy
ECochG diagnostic accuracy 74% (sensitivity 65%, specificity 78%); cVEMP accuracy 67% (sensitivity 62%, specificity 68%)
Bembenek et al (2015) - MEPs in Wilson's disease
Abnormal MEPs reported in 20-70% across small heterogeneous studies

The document scope covers clinical use and coverage criteria for evoked potential studies across diagnostic and screening contexts and distinguishes intraoperative monitoring (see CPB 0697) from non‑intraoperative testing. It also differentiates limited vs comprehensive auditory testing for neonatal screening: limited ABR or limited OAE are appropriate for newborn/infant screening, with referral for comprehensive testing only if screening is failed or if indicated (neonates/children < 3 years).

Term	Definition
BAER
Also known as auditory brainstem response (ABR), auditory evoked potentials (AEPs), brainstem auditory evoked potentials (BAEP), BERA, BSER, BSRA.
cVEMP
Cervical vestibular evoked myogenic potential.
SSEP / SEP
Somatosensory evoked potentials that assess conduction in somatosensory pathways.
VEP / VER
Visual evoked potentials/responses measuring visual pathway function using flashes or pattern reversal stimuli.
VEMP
Vestibular evoked myogenic potentials assessing saccular/vestibular function recorded from neck/ocular muscles.
oVEMP
Ocular vestibular evoked myogenic potential, assesses extra-ocular muscle responses to vibration or sound stimuli.
RoVEMP
Repetitive ocular vestibular evoked myogenic potential, a repetitive-stimulation variant used in myasthenia gravis evaluation.
MEP
Monitors motor pathways; transcranial electrical stimulation elicits excitation of corticospinal projections.
SSEP
Monitors the dorsal column–medial lemniscus pathway; stimulation of peripheral sensory receptors initiates peripheral sensory nerves through the nerve root to dorsal root ganglia.

Medicare Determinations

Name	Number	Type	Effective Date
Novitas Solutions L32640 - Neurophysiology Evoked Potentials (NEPs)
L32640
LCD
2012-11-19

Revision History

Policy Summary

PayerAetna

PolicyEvoked Potential Studies

Policy CodePolicy 0181

Change TypeNo material change

Effective Date

Last ReviewOct 25, 2023

Next Review Date

Key ActionDocument specific indication that meets one of the listed medically necessary criteria when ordering SEPs/DSEPs.

SourceLink

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Evoked Potential Studies

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Coverage Summary

Thresholds / Cut-offs

Acute anoxic encephalopathy timingwithin 3 days of the anoxic event

Pediatric BAER screening ageinfants and children under 3 years of age (limited tests for screening)

VEP member agemembers > 3 months of age for listed ICD-10 coverage

oVEMP unilateral decrement cut-off>= 15.2 % (Valko 2016)

oVEMP bilateral decrement cut-off>= 20.4 % (Valko 2016)

RoVEMP cut-off>= 14.3 % versus neuromuscular controls (De Meel 2020)

RoVEMP mean decrementMean 28.4% ± 32.2 in MG patients (De Meel 2020)

ECochG SP/AP cut-off> 0.4 (diagnostic benefit maximized when SP/AP > 0.4) (Xu 2019)

VEP rate of change+1.951 ms/year (>=3 months interval, no optic neuritis) (Ringelstein 2020)

Medical-Necessity Criteria

Somatosensory evoked potentials (SEPs, SSEPs) - Medically Necessary

Considered medically necessary for any of the following indications:

To evaluate acute anoxic encephalopathy (within 3 days of the anoxic event).within 3 days

To evaluate persons with suspected brain death.

To localize the cause of a central nervous system deficit seen on exam but not explained by lesions seen on CT or MRI.

To manage persons with spinocerebellar degeneration (e.g., Friedreich's ataxia, olivopontocerebellar degeneration).

Unexplained myelopathy.

For intraoperative SSEPs under certain conditions (see CPB 0697 - Intraoperative Neurophysiological Monitoring).

SEPs / DSEPs - Experimental and Investigational

Considered experimental and investigational for all other indications because effectiveness not established.

SEPs monitoring during trigger point injection for management of low back pain.

SEPs for radiculopathies and peripheral nerve lesions where standard nerve conduction velocity studies are diagnostic.

SEPs for diagnosis of carpal tunnel syndrome/ulnar nerve entrapment.

SEPs in conscious persons with severe spinal cord or head injuries.

SEPs in diagnosis of cervical spondylitic myeloradiculopathy.

SEPs in diagnosis of thoracic outlet syndrome.

SEPs in diagnosis or management of acquired metabolic disorders (e.g., lead toxicity, B12 deficiency).

SEPs in diagnosis or management of amyotrophic lateral sclerosis (ALS).

Short-latency SSEP study for evaluation of movement disorders.

Pre-operative SSEP of bilateral tibial somatosensory pathways prior to scoliosis surgery.

Evoked potential studies for Kennedy's syndrome/disease.

Other non-listed indications not established.

Visual Evoked Potentials (VEPs) - Medically Necessary

Considered medically necessary for any of the following indications:

To diagnose and monitor multiple sclerosis (acute or chronic phases).

To evaluate signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons).

To identify persons at increased risk for developing clinically definite multiple sclerosis (CDMS).

To localize the cause of a visual field defect not explained by lesions seen on CT or MRI, metabolic disorders, or infectious diseases.

Not recommended: Standard or automated VEPs are considered experimental and investigational for routine screening of infants and other persons.

VEPs - Experimental and Investigational

VEPs are considered experimental and investigational for other indications not listed above.

VEPs for detecting amnestic mild cognitive impairment.

VEPs for evaluation and monitoring of birdshot chorioretinopathy.

Visual evoked potential for evaluation of neuromyelitis optica spectrum disorder.

Brain Stem Auditory Evoked Response (BAER/ABR) - Medically Necessary

Considered medically necessary for any of the following:

For intraoperative monitoring (see CPB 0697 - Intraoperative Neurophysiological Monitoring).

To assess brain death or profound metabolic coma in selected cases where diagnosis or outcome is unclear from standard tests (e.g., EEG).

To assess recovery of brainstem function after surgical removal of lesion compressing brainstem.

To diagnose and monitor demyelinating and degenerative diseases affecting brain stem (e.g., central pontine myelinolysis, OPC degeneration).

To diagnose post-meningitic deafness in children.

To diagnose suspected acoustic neuroma.

To evaluate infants and children with suspected hearing loss not effectively measured/monitored through audiometry.

To localize cause of a CNS deficit seen on exam but not explained by CT or MRI.

To screen infants and children under 3 years of age for hearing loss (limited auditory evoked potentials or limited OAE only; comprehensive testing only if indicated after fail).members < 3 yrs

BAER/ABR - Experimental and Investigational

BAERs are considered experimental and investigational for all other indications not listed above.

BAERs as a test to identify persons at increased risk for developing clinically definite multiple sclerosis (CDMS).

BAERs for syringomyelia and syringobulbia.

Other non-listed indications.

Cervical Vestibular Evoked Myogenic Potential (cVEMP) - Medically Necessary

Considered medically necessary when specific preconditions met:

Evaluation of individuals with vertigo for semicircular canal dehiscence syndrome (SCDS).

Requires prior comprehensive evaluation

A comprehensive evaluation (history, physical, audiometry, electronystagmography or videonystagmography, electrocochleography, brainstem audiometry) has been performed and results are inconclusive.

cVEMP / VEMP / oVEMP - Experimental and Investigational

Considered experimental and investigational for other specified uses:

cVEMP for evaluation of vestibular function specifically related to the saccule/utricle.

cVEMP for diagnosis of benign paroxysmal positional vertigo and vestibular neuritis.

oVEMP for diagnosis of benign paroxysmal positioning vertigo, myasthenia gravis, or vestibular neuritis.

oVEMP for evaluation of vestibular function specifically related to the saccule/utricle.

VEMP for diagnosis of Meniere's disease or delayed endolymphatic hydrops; differentiation of Meniere disease from vestibular migraine.

Evoked Otoacoustic Emissions (OAE) - Medically Necessary (Screening)

Screening/OAE coverage rules:

For purposes of screening (including neonatal screening), only limited auditory evoked potentials or limited evoked otoacoustic emissions (OAE) are considered medically necessary.

Neonates, infants and children under 3 years who fail screening are referred for comprehensive auditory evoked response testing or comprehensive OAE.members < 3 yrs

Evoked OAE is medically necessary to screen children ≤3 years who did not have initial neonatal screening and/or cannot be effectively measured or monitored through audiometry.≤3 years

Motor Evoked Potentials (non-intraoperative) - Not Covered / Experimental

Motor evoked potentials (other than intraoperative with SSEPs) are not covered/considered experimental for indications listed:

Central motor evoked potential studies (CPT 95928, 95929, 95939) are not covered for listed indications.

Not covered for evaluation of Wilson's disease (E83.01).

Codes Not Covered (motor evoked potentials)

CPT and ICD-10 codes explicitly listed as not covered for indications in the clinical policy bulletin (CPB):

CPT codes not covered for indications listed in the CPB:

95928 — Central motor evoked potential study (transcranial motor stimulation); upper limbs.
95929 — Central motor evoked potential study (transcranial motor stimulation); lower limbs.
95939 — Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.

ICD-10 codes not covered for indications listed in the CPB:

E83.01 — Wilson's disease.

Codes Not Covered (VEMP)

Vestibular evoked myogenic potentials CPT/ICD-10 codes listed as not covered for indications in the CPB:

CPT codes not covered for indications listed in the CPB:

92517 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP).
92518 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP).
92519 — Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP).

ICD-10 codes not covered for indications listed in the CPB:

G43.801 - G43.819 — Other migraine [vestibular migraine].
H81.01 - H81.09 — Meniere's disease.
H81.10 - H81.13 — Benign paroxysmal vertigo.
H81.20 - H81.23 — Vestibular neuronitis.

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Other ICD-10 codes referenced (screening exam only for members < 3 yrs.)

ICD-10 codes listed in this part as related to screening or examination contexts:

F80.0 - F80.9 — Specific developmental disorders of speech and language.

R94.120 - R94.128 — Abnormal results of function studies of ear and other special senses.

Z01.110 — Encounter for hearing examination following failed hearing screening.

Z01.118 — Encounter for examination of ears and hearing with other abnormal findings.

Z00.121 - Z00.129 — Encounter for routine child health examination with/without abnormal findings.

Documentation Requirements

To qualify for coverage, medical necessity criteria and documentation must be present in the medical record:

All medical necessity criteria must be clearly documented in the member's medical record and made available upon request.

The physician’s evoked potential report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.

Coding

Somatosensory evoked potentials (covered if criteria met)CPT|ICD-10Covered

95925	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs.
95926	in lower limbs.
95927	in the trunk or head.
95938	in upper and lower limbs.
G11.1	Early-onset cerebellar ataxia [Friedreich's ataxia].
G23.8	Other specified degenerative diseases of basal ganglia [OPC degeneration].
G35	Multiple sclerosis [with clinically silent lesions].
G36.0 - G37.9	Other demyelinating diseases of central nervous system.
G93.1	Anoxic brain damage, not elsewhere classified.
G93.82	Brain death.

1–10 of 11

1/2

Somatosensory evoked potentials (ICD-10 not covered examples)ICD-10Not Covered

E53.8	Deficiency of other specified B group vitamins [diagnosis and management of acquired metabolic disorders].
F43.10 - F43.12	Posttraumatic stress disorder.
E70.0 - E89.89	Metabolic disorders [diagnosis and management of acquired metabolic disorders].
F90.0 - F90.9	Attention-deficit hyperactivity disorders.
G12.21	Amyotrophic lateral sclerosis.
G12.8 - G12.9	Other and unspecified muscular atrophies.
G25.81 - G25.89	Other specified extrapyramidal and movement disorders.
G25.9	Extrapyramidal and movement disorder, unspecified.
G54.0	Brachial plexus disorders [thoracic outlet syndrome].
G56.00 - G59	Mononeuropathies of upper and lower limbs [radiculopathies, peripheral nerve lesions, carpal tunnel].

1–10 of 14

1/2

Visual evoked potentials (covered if criteria met)CPT|ICD-10Covered

95930	Visual evoked potential (VEP) testing central nervous system, checkerboard or flash.
A39.82	Meningococcal retrobulbar neuritis.
A52.10 - A52.19	Symptomatic neurosyphilis.
A69.20	Lyme disease, unspecified.
G35	Multiple sclerosis.
G36.0 - G37.9	Other demyelinating diseases of central nervous system.
G93.1	Anoxic brain damage, not elsewhere classified.
H47.011 - H47.9	Disorders of the optic nerve and visual pathways.
H53.001 - H53.9	Visual disturbances.
H81.01 - H83.2x9	Disorders of vestibular function.

Visual evoked potentials (not covered / not recommended codes)CPTNot Covered

0333T

Visual evoked potential, screening of visual acuity, automated [not covered for screening].

Brain stem auditory evoked response (BAER) - comprehensive (covered if criteria met)CPT|ICD-10Covered

92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report.
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report.
G93.82	Brain death [for members >3 months of age].
G93.1	Anoxic brain damage.
G35	Multiple sclerosis.
H83.3 - H94.83	Other disorders of ear and hearing loss.
Z01.110	Encounter for hearing examination following failed hearing screening.
Z79.2	Long-term (current) use of antibiotics [damage due to ototoxic drugs].

Brain stem auditory evoked response (limited) (covered if criteria met)CPT|ICD-10Covered

92650	Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis.
92651	Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report.

Evoked otoacoustic emissions (OAE) - CPTs (covered if criteria met)CPTCovered

92558	Evoked otoacoustic emissions, screening (automated analysis).
92587	Evoked otoacoustic emissions; limited (single stimulus level).
92588	Comprehensive or diagnostic evaluation (comparison at multiple levels and frequencies) [not covered for routine neonatal screening].

cVEMP CPTs (covered if criteria met)CPTCovered

92517	Vestibular evoked myogenic potential (VEMP) testing; cervical (cVEMP).
92518	VEMP testing; cervical and ocular (cVEMP and oVEMP).

Motor evoked potentials - CPTs not coveredCPT|ICD-10Not Covered

95928	Central motor evoked potential study; upper limbs.
95929	Central motor evoked potential study; lower limbs.
95939	Central motor evoked potential study; upper and lower limbs.
E83.01	Wilson's disease (ICD-10) - listed as not covered indication.

VEMP CPTs listed as not covered for indications in CPBCPTNot Covered

92517	Vestibular evoked myogenic potential (VEMP) testing; cervical (cVEMP) (listed in not covered section for certain indications).
92518	VEMP; ocular (oVEMP).
92519	VEMP; cervical and ocular.

CPT codes explicitly NOT COVERED (motor evoked potentials)CPTNot Covered

95928	Central motor evoked potential study (transcranial motor stimulation); upper limbs.
95929	Central motor evoked potential study (transcranial motor stimulation); lower limbs.
95939	Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.

CPT codes explicitly NOT COVERED (VEMP)CPTNot Covered

92517	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP).
92518	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP).
92519	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP).

ICD-10 codes listed as NOT COVERED for CPB indications (VEMP/motor evoked contexts)ICD-10Not Covered

E83.01	Wilson's disease.
G43.801 - G43.819	Other migraine [vestibular migraine].
H81.01 - H81.09	Meniere's disease.
H81.10 - H81.13	Benign paroxysmal vertigo.
H81.20 - H81.23	Vestibular neuronitis

ICD-10 codes referenced for screening/exam contexts (members < 3 yrs. or exams)ICD-10

F80.0 - F80.9	Specific developmental disorders of speech and language.
R94.120 - R94.128	Abnormal results of function studies of ear and other special senses.
Z01.110	Encounter for hearing examination following failed hearing screening.
Z01.118	Encounter for examination of ears and hearing with other abnormal findings.
Z00.121 - Z00.129	Encounter for routine child health examination with/without abnormal findings.

Provider Actions & Billing Guidance

Documentation Required

SEPs/DSEPs indication documentation

Affected codes: 95925, 95926, 95927, 95930

Documentation Required

cVEMP pre-evaluation requirement

Affected codes: 92517
Affected codes: 92518

Documentation Required

OAE neonatal screening workflow

Documentation Required

Use appropriate ICD-10 codes for screening context

Use applicable ICD-10 screening/failure codes as documented in the patient's record

Billing Rule

Do not bill excluded CPT codes for CPB-listed indications

Documentation Required

VEMP as part of diagnostic battery for Meniere disease

Use VEMP as part of diagnostic battery for Meniere disease

Documentation Required

oVEMP/RoVEMP utility

oVEMP/RoVEMP may aid MG diagnosis

Documentation Required

cVEMP abnormality predictive note

cVEMP abnormalities may predict conversion to Meniere disease

Documentation Required

Medical record documentation for coverage

Medical record must contain history, prior testing, rationale, report, and management impact

Documentation Required

BAER-specific documentation

BAER-specific documentation: indication, parameters, limited vs comprehensive, follow-up plan

Billing Rule

Baseline testing reporting

Baseline testing reporting — use limited screening codes for neonatal screening; comprehensive tests require documented medical necessity

Documentation Required

Interpretation caution for cooled neonates

Exercise caution when interpreting BAER/evoked potential results in cooled neonates; document the clinical context (therapeutic hypothermia) and note potential effects of cooling on test results.

Interpretation caution for cooled neonates

Documentation Required

VEMP as part of battery

VEMP should be documented as part of a diagnostic battery

Evidence, Definitions, and Notes

Study / Measure	Result / Value
Van Laerhoven et al (2013) pooled VEP performance
VEPs sensitivity 0.90 (0.74-0.97); specificity 0.92 (0.68-0.98)
UpToDate / Wijdicks et al (SSEP prognostic) - post-cardiac arrest
Bilateral absence of N20 within 1-3 days predicts poor outcome with pooled LR 12.0 and false-positive rate 0%
Garfinkle et al (2015) - neonatal SEPs after hypothermia
Bilateral absent N19 PPV 0.36; NPV 0.93 (shows lower PPV with therapeutic hypothermia)
Silverstein et al (2014) - saphenous nerve SSEP intraoperative series
Changes in SSEP in 5 of 41 procedures; 3 patients woke with femoral nerve deficit; none with stable SSEP developed deficits
Fix et al (2015) - FVEP-P2 in MCI/AD
Double-flash 100 ms condition showed higher predictive accuracy vs single-flash for FVEP-P2 latency
Valko et al (2016) - oVEMP for myasthenia gravis
oVEMP sensitivity 89%, specificity 64% (unilateral decrement >=15.2%)
De Meel et al (2020) - RoVEMP for MG
RoVEMP cut-off >=14.3%: sensitivity 67%, specificity 82%; mean decrement 28.4% ± 32.2 in MG patients
Egami et al (2013) - VEMP for Meniere's disease
VEMP sensitivity 50.0%, specificity 48.9%; combined VEMP+caloric sensitivity 65.8%
Xu et al (2019) - ECochG/cVEMP diagnostic accuracy
ECochG diagnostic accuracy 74% (sensitivity 65%, specificity 78%); cVEMP accuracy 67% (sensitivity 62%, specificity 68%)
Bembenek et al (2015) - MEPs in Wilson's disease
Abnormal MEPs reported in 20-70% across small heterogeneous studies

Term	Definition
BAER
Also known as auditory brainstem response (ABR), auditory evoked potentials (AEPs), brainstem auditory evoked potentials (BAEP), BERA, BSER, BSRA.
cVEMP
Cervical vestibular evoked myogenic potential.
SSEP / SEP
Somatosensory evoked potentials that assess conduction in somatosensory pathways.
VEP / VER
Visual evoked potentials/responses measuring visual pathway function using flashes or pattern reversal stimuli.
VEMP
Vestibular evoked myogenic potentials assessing saccular/vestibular function recorded from neck/ocular muscles.
oVEMP
Ocular vestibular evoked myogenic potential, assesses extra-ocular muscle responses to vibration or sound stimuli.
RoVEMP
Repetitive ocular vestibular evoked myogenic potential, a repetitive-stimulation variant used in myasthenia gravis evaluation.
MEP
Monitors motor pathways; transcranial electrical stimulation elicits excitation of corticospinal projections.
SSEP
Monitors the dorsal column–medial lemniscus pathway; stimulation of peripheral sensory receptors initiates peripheral sensory nerves through the nerve root to dorsal root ganglia.

Name	Number	Type	Effective Date
Novitas Solutions L32640 - Neurophysiology Evoked Potentials (NEPs)
L32640
LCD
2012-11-19

Name

Number

Type

Effective Date

Novitas Solutions L32640 - Neurophysiology Evoked Potentials (NEPs)

L32640

LCD

2012-11-19