Evoked Potential Testing
Customize your policy alerts
Sign up for Arizona Complete Health Policy CP.MP.134 alerts
Get alerted when Policy CP.MP.134 changes without checking for updates manually.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Evoked Potential Testing
inv-01: Medically necessary indications
Covered when indications below are met (policy I and II):
From policy section I.B
From policy section I.C
From policy section II
inv-02: Insufficient evidence / investigational indications
Indications with insufficient evidence (policy III):
From policy section III
inv-03: Not medically necessary indications
Not medically necessary (policy IV):
From policy section IV.A
From policy section IV.B
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
| 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. |
| 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 |
Provider Requirements, Prior Authorization, and Documentation
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.
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.
- Providers should confirm member eligibility, benefits, and any applicable exclusions prior to scheduling or performing services.
Documentation and Claims Support
Documentation Expectations: Submit complete clinical documentation to support the medical necessity of billed services. Documentation should clearly justify the indication for testing and show how the member meets the coverage criteria in this policy.
- Include the performed CPT code(s) and a copy of the interpreting clinician's report with findings and impression.
- Attach relevant clinical records such as history, physical exam, prior imaging or test results, and progress notes that support the diagnosis and rationale for testing.
- Ensure documentation supports the specific indication claimed (e.g., suspected optic nerve disorder for VEP, intraoperative monitoring indications for SEP/MEP/BAEP).
Policy Guidance and Administrative Notes
Policy as a Guide; Administrative Alignment: This clinical policy is a coverage guide only. Coverage and payment decisions remain subject to the Health Plan's terms, conditions, exclusions, and applicable state or federal requirements. For Medicaid members, state Medicaid provisions supersede this policy when conflicts exist.
- Providers must follow Arizona Complete Health prior authorization and claim submission processes; the Health Plan may amend or withdraw this clinical policy at any time.
- For Medicare members, review applicable NCDs/LCDs and Medicare Coverage Articles prior to applying this policy.
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.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.