CurrentAmbetter NevadaPolicy CP.MP.134

Evoked Potential Testing (PDF)

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Defines medical necessity criteria for evoked potential testing (somatosensory, brainstem auditory, visual, and motor evoked potentials), intraoperative monitoring, indications considered insufficient evidence, non-covered indications, and associated CPT/ICD-10 coding implications for health plans affiliated with Centene Corporation (Ambetter Nevada).

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CurrentAmbetter NevadaPolicy CP.MP.134

Evoked Potential Testing (PDF)

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Coverage Summary

Scope: This policy defines medical necessity criteria for evoked potential testing — including somatosensory (SSEP), brainstem auditory (BAEP), visual (VEP), and motor evoked potentials (MEP) — and for intraoperative neurophysiologic monitoring. The policy applies to health plans affiliated with Centene Corporation (Ambetter Nevada) and is the current policy version as of 09/25.

Policy Metadata and Key Counts

policy_numberCP.MP.134

payerAmbetter Nevada (health plans affiliated with Centene Corporation)

last_review2025-09-25

effective_date

next_review

statusCURRENT

subjectEvoked Potential Testing

Revision/Approval (most recent)Revision Date = 09/25; Approval Date = 09/25

Referenced CPT codes count11

ICD-10 code groups count1 (long supporting list)

Medically necessary modality types (stats)3

Intraoperative modalities considered med necessary (stats)1

Modalities with insufficient evidence (stats)2

Specific non-covered visual VEP indications (stats)3

Medical Necessity Criteria

Insufficient Evidence (Not Supported)

There is insufficient evidence in peer-reviewed literature to support the following uses:

ANY of the following

ANY of the following
- Intraoperative monitoring of visual evoked potentials
- Motor evoked potentials from transcranial magnetic stimulation

Not Medically Necessary

Evoked potential testing is not medically necessary for ANY of the following:

ANY of the following

ANY of the following

Coding

Covered/Referenced CPT CodesCPTCovered

92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report
95925	Short-latency somatosensory evoked potential study; upper limbs
95926	Short-latency somatosensory evoked potential study; lower limbs
95927	Short-latency somatosensory evoked potential study; trunk or head
95928	Central motor evoked potential study (transcranial motor stimulation); upper limbs
95929	Central motor evoked potential study (transcranial motor stimulation); lower limbs
95930	Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report
95938	Short-latency somatosensory evoked potential study; upper and lower limbs
95939	Central motor evoked potential study (transcranial motor stimulation); upper and lower limbs

1–10 of 12

1/2

Deleted/Removed Codes (historical)CPT|HCPCSNot Covered

92585	Deleted 1/1/21 (historical)
95940	Removed (intraoperative) - historical
95941	Removed (intraoperative) - historical
G0453	Removed HCPCS - historical

ICD-10 Codes Supporting Coverage CriteriaICD-10

A17.0-A17.89	Tuberculosis of nervous system
A39.82	Meningococcal retrobulbar neuritis
C30.1	Malignant neoplasm of middle ear
C41.0	Malignant neoplasm of bones of skull and face
C41.2	Malignant neoplasm of vertebral column
C70.0-C70.9	Malignant neoplasm of meninges
C71.0-C71.9	Malignant neoplasm of brain
C72.0-C72.9	Malignant neoplasm of spinal cord, cranial nerves and other parts of the central nervous system
C79.31-C79.32	Secondary malignant neoplasm of brain and cerebral meninges
C79.49	Secondary malignant neoplasm of other parts of nervous system

1–10 of 56

1/6

Provider Actions

Documentation Required

Support testing with indication-specific documentation

Document the clinical indication that matches the policy’s medically necessary criteria. Include indication-specific details (for example timing or imaging findings) and, when applicable, that imaging does not explain the CNS deficiency.

Acute anoxic encephalopathy within the initial 72 hours of onset (e.g., after cardiac arrest)
Suspected optic nerve disorder or demyelinating optic neuritis
Need for intraoperative monitoring during surgeries that may affect neural structures

Billing Rule

Use current CPT codes referenced

Report evoked potential services using the current, appropriate CPT codes listed in the policy. Do not bill deleted or removed codes for dates of service after their deletion.

Background, Evidence & Definitions

Background: Evoked potentials record electrical responses in the central and peripheral nervous systems to specific sensory or motor stimulation to help diagnose or localize nerve damage, assess prognosis, and guide intraoperative monitoring to reduce neurologic injury. Professional guidance cited includes the American Speech-Language-Hearing Association (position statement on intraoperative monitoring), the American Academy of Neurology (evidence-based guideline supporting intraoperative monitoring utility), and the American Clinical Neurophysiology Society (technical guidelines on evoked potentials).

Source	Summary
AAN guideline (2012)
Spinal cord intraoperative monitoring with SSEP/MEP predicts adverse surgical outcomes; studies showed occurrences of severe deficits when evoked potential changes occurred and none when they did not.
ACNS Guideline 9A (2006)
Provides technical specifications for evoked potentials (amplifier, safety, filtering, calibration, replication, interpretation).

Term	Definition
Evoked Potentials
Electrical recordings of afferent and efferent networks in response to specific stimulation used to diagnose or locate nerve damage.
SSEP
Somatosensory evoked potentials.
BAEP
Brainstem auditory evoked potentials.
VEP
Visual evoked potentials.
TCeMEP
Transcranial electrical motor evoked potentials.

Medicare Local Coverage Determinations

Name	Number	Effective Date	Type
Neurophysiology Evoked Potentials (NEPs)
L34975
2015-10-01
LCD

Revision History

09/25revisionLatest

Annual review. Description and background updated with no clinical significance. Coding reviewed and updated. Reviewed by an external specialist. Approval Date = 09/25.

08/21revision

Annual review completed. References reviewed, updated, and reformatted. Coding reviewed and updated. Removed intraoperative CPT codes 95940 and 95941 and HCPCS code G0453. Approval Date = 08/21.

04/21revision