CurrentArizona Complete HealthPolicy CP.MP.134

Evoked Potential Testing

This policy defines medical necessity, coverage criteria, and coding guidance for evoked potential (EP) testing — including somatosensory, brainstem auditory, visual, and motor EPs — for members of health plans affiliated with Centene Corporation (Arizona Complete Health). It applies to providers requesting or performing EP testing.

Policy Summary

PayerArizona Complete Health

PolicyEvoked Potential Testing

Policy CodePolicy CP.MP.134

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit supporting clinical documentation with the appropriate CPT code(s) and diagnosis consistent with policy indications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6types of sensory evoked potential testing mentioned

72 hoursprognosis time window (coma/anoxic)

supportedintraoperative EPs supported

9literature/guideline citations

Centenedocument ownership

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Coverage Criteria for Evoked Potential Testing

inv-01: Medically necessary indications

Covered when indications below are met (policy I and II):

Brainstem Auditory EP - Covered Indications: Brainstem auditory EP testing is medically necessary for: (1) assessment of brainstem function (e.g., during tumor infiltration of the brainstem and after surgical lesion removal); (2) diagnosis and monitoring of demyelinating and degenerative diseases affecting the brainstem (e.g., multiple sclerosis, central pontine myelinolysis, olivopontocerebellar degeneration); (3) diagnosis of lesions in the auditory system (e.g., acoustic neuroma); (4) aid in evaluation of prognosis in coma within the initial 72 hours of onset (excluding evaluation of brain death); (5) screening for hearing loss in infants and preverbal children or children with developmental delay or intellectual disability; (6) intraoperative monitoring during surgeries that may affect neural structures.

From policy section I.B

Visual EP - Covered Indications: Visual EP testing is medically necessary for: (1) diagnosis and monitoring of optic nerve function and during demyelinating disorders of the optic nerve (e.g., multiple sclerosis, optic neuritis); (2) assessment of suspected disorder of the optic nerve, optic chiasm, or pre-chiasmic radiations (visual EPs are not useful for post-chiasmic disease); (3) evaluation of visual loss in individuals unable to communicate.

From policy section I.C

Intraoperative EP Monitoring - Covered: Somatosensory EPs, motor EPs using transcranial electrical stimulation, and brainstem auditory EPs are medically necessary for monitoring during intracranial, orthopedic, spinal, and vascular surgeries.

From policy section II

inv-02: Insufficient evidence / investigational indications

Indications with insufficient evidence (policy III):

Insufficient evidence: The published peer-reviewed literature is insufficient to support: (1) intraoperative monitoring using visual evoked potentials; (2) motor evoked potentials generated by transcranial magnetic stimulation (TMS).

From policy section III

inv-03: Not medically necessary indications

Not medically necessary (policy IV):

Not medically necessary - Motor EPs non-operative: Motor evoked potentials for non-operative monitoring are not medically necessary.

From policy section IV.A

Not medically necessary - Visual EPs specific conditions: Visual evoked potentials are not medically necessary for: (1) glaucoma or glaucoma suspect; (2) amblyopia; (3) diabetes.

From policy section IV.B

Not medically necessary - Other unspecified: Evoked potential testing is not medically necessary for evaluation/assessment of conditions other than those specified as covered in this policy.

From policy section IV.C

The policy identifies two specific exclusions under the supported indications: intraoperative visual evoked potentials and motor evoked potentials produced by transcranial magnetic stimulation (TMS). These are listed in the section on insufficient evidence and therefore are not supported indications for coverage under this policy.

The policy explicitly states that motor evoked potentials for non‑operative monitoring are not medically necessary. It also lists specific circumstances in which visual evoked potentials are not medically necessary, including for glaucoma or glaucoma suspect, amblyopia, and diabetes.

Coverage under this clinical policy is subject to the member's plan terms, applicable legal and regulatory requirements, and any Health Plan administrative policies. Where state Medicaid provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. The clinical policy is a guide to medical necessity but does not replace provider judgment or plan‑level contract terms.

Coding — CPT and Diagnosis Codes

Referenced CPT CodesCPT

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.

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ICD-10-CM diagnosis codes that support coverage criteria (selected examples and ranges)ICD-10

A17.0-A17.89	Tuberculosis of nervous system
A39.82	Meningococcal retrobulbar neuritis
C30.1	Malignant neoplasm of middle ear
C71.0-C71.9	Malignant neoplasm of brain
D32.0-D32.9	Benign neoplasm of meninges
E08.40-E08.49	Diabetes mellitus with diabetic neuropathy/neurological complications
G35	Multiple sclerosis
G11.11	Friedreich ataxia
H46.0-H46.9	Optic neuritis
H90.0-H90.72	Conductive and sensorineural hearing loss

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Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization may be required for the CPT codes listed in this policy. Providers should verify prior authorization requirements with Arizona Complete Health before performing services and submit prior authorization requests when applicable.

Affected CPT codes include, but may not be limited to: 92652, 92653, 95925–95930, 95938–95939, 0333T, 95930 (VEP). Confirm current code list with the payer prior to submission.

Denial Risk

Denial Risk Tied to Coverage Documents

Denial Risk for Non‑Covered or Excluded Services: Claims submitted for services that are not supported by medical necessity criteria, are listed as not medically necessary in this policy, or are excluded under the member's contract are at risk for denial.

Denials may be based on: services not meeting the medical necessity criteria in this policy; services excluded by the member's benefit contract; or conflicts with state Medicaid or Medicare coverage determinations.

Definitions and Background

Evoked potentials record electrical responses generated in the central and peripheral nervous system after specific sensory or motor stimulation and are used to localize or characterize dysfunction along neural pathways. Common types include somatosensory evoked potentials (SSEPs), which assess sensory pathways after peripheral nerve stimulation; brainstem auditory evoked potentials (BAEPs), which evaluate auditory pathway and brainstem function; visual evoked potentials (VEPs), which assess conduction in the visual pathway; and motor evoked potentials (MEPs), which evaluate motor pathways via cortical or spinal stimulation. Clinically, EPs are used both for diagnostic evaluation (for example, in demyelinating disease, optic nerve disorders, or peripheral neuropathy) and for intraoperative neuromonitoring to help reduce the risk of permanent postoperative neurologic injury.

Somatosensory evoked potentials definition

DefinitionSomatosensory evoked potentials (SSEPs) are recordings generated by peripheral nerve stimulation and recorded from the central nervous system to assess sensory pathways and help localize site of nerve dysfunction.

Primary useDiagnosis of nerve damage and localization of sensory pathway dysfunction when clinical exam or imaging is inconclusive.

Intraoperative roleUsed for monitoring during surgeries that may affect neural structures to help avoid intraoperative injury to sensory pathways.