CurrentIndependent HealthPolicy M2018031403

Vestibular Dysfunction Evaluation

Defines Independent Health's coverage and medical necessity criteria for vestibular function tests (ENG/VNG, VEMP, vHIT, CDP, SVV, UCS) across applicable product lines including commercial, Medicare Advantage, and state plans in NC.

Policy Summary

PayerIndependent Health

PolicyVestibular Dysfunction Evaluation

Policy CodePolicy M2018031403

Change TypeClarified coverage and added investigational determinations

Effective DateMay 1, 2018

Next Review Date

Key ActionObtain pre-authorization for CDP, VEMP, and vestibular rehabilitation using virtual reality devices before scheduling services.

SourceLink

POLICY UPDATE CHANGES

Pre-authorization is required for Computerized Dynamic Posturography, Vestibular Evoked Myogenic Potential, and vestibular rehabilitation utilizing virtual reality devices; other services do not require pre-authorization at present.

Videonystagmography (VNG) is designated a medically necessary alternative to ENG for assessment of vestibular disorders.

Vestibular rehabilitation using virtual reality devices is considered experimental and investigational.

ENG/VNG coveredTests medically necessary

VEMPInvestigational - not covered

vHITInvestigational - not covered

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VR rehabRequires pre-auth

Coverage determinations for vestibular testing

Test-specific coverage determinations

Coverage determinations by test

ENG/VNG: Electronystagmography (ENG) and Videonystagmography (VNG) are considered medically necessary for evaluation of persons with symptoms of vestibular disorders (dizziness, vertigo, disequilibrium or imbalance). VNG is a medically necessary alternative to ENG.

VEMP: Vestibular evoked myogenic potential (VEMP) tests are considered investigational due to insufficient clinical evidence in the peer-reviewed medical literature to support whether VEMP can accurately identify vestibular function.

Pre-authorization required as noted elsewhere.

vHIT: Video head impulse test (vHIT) tests are considered investigational due to insufficient clinical evidence in the peer-reviewed medical literature to support the use of vHIT for assessing balance problems.

CDP/SVV/UCS: Computerized Dynamic Posturography (CDP), Subjective Visual Vertical (SVV) and Unilateral Centrifugation (UCS) are considered investigational due to insufficient clinical evidence in the peer-reviewed medical literature to support their use for assessing balance problems, detecting vestibular dysfunction, distinguishing peripheral versus central causes, or demonstrating improved health outcomes.

Pre-authorization required for CDP.

Vestibular rehabilitation with virtual reality devices: Vestibular rehabilitation utilizing virtual reality devices (including but not limited to the VIVE device) is considered experimental and investigational because efficacy has not been established in the peer-reviewed literature.

Pre-authorization required.

Vestibular rehabilitation that utilizes virtual reality devices (for example, consumer systems such as the VIVE) is designated experimental and investigational and is therefore excluded from coverage because its efficacy has not been established in the peer‑reviewed medical literature.

Both Vestibular Evoked Myogenic Potential (VEMP) testing and the Video Head Impulse Test (vHIT) are considered investigational (not medically necessary). This determination is based on insufficient clinical evidence in the peer‑reviewed literature supporting their accuracy or clinical usefulness for identifying vestibular dysfunction or for assessing balance problems.

For VEMP specifically, published guideline assessments (for example, the American Academy of Neurology) and the available peer‑reviewed literature do not provide adequate evidence that VEMP reliably identifies saccular/utricular function or that it improves diagnostic or patient outcomes.

Regulatory and procedure codes

Regulatory / Ordering Ambulatory Procedure Codes referencemixed

No codes listed

Prior authorization and documentation requirements

Prior Authorization

Prior Authorization Required

Pre-authorization is required for the following services: Computerized Dynamic Posturography (CDP), Vestibular Evoked Myogenic Potential (VEMP), and vestibular rehabilitation utilizing virtual reality devices (e.g., VIVE). For all other vestibular diagnostic and treatment services in this policy, pre-authorization is not required at this time; however the clinical criteria will be used for retroactive review when applicable.

Computerized Dynamic Posturography (CDP)
Vestibular Evoked Myogenic Potential (VEMP)
Vestibular rehabilitation utilizing virtual reality devices (including but not limited to VIVE)

Denial Risk

Pre-authorization consequence / denial risk

Failure to obtain required pre-authorization for CDP, VEMP, or virtual-reality–based vestibular rehabilitation may result in claim denial or delay. Providers should obtain authorization before scheduling these services to avoid denial risk.

Clinical background and scope

Vertigo and related symptoms (dizziness, disequilibrium, imbalance) commonly result from asymmetry of the vestibular system. Typical clinical evaluation includes a focused history and neurologic examination, positional testing such as the Dix‑Hallpike maneuver, audiometry and imaging as indicated, and targeted vestibular function testing.

Common vestibular function tests include ENG/VNG to record and quantify spontaneous and induced nystagmus, rotational testing and bedside maneuvers such as the Head Impulse Test. Specialized tests described in the literature include vHIT—which uses high‑speed video goggles to quantify eye and head velocities during small, rapid head impulses—and VEMP, which records otolith‑dependent reflexes from cervical or ocular muscles after sound or vibration stimulation. Computerized Dynamic Posturography (CDP) is a moving‑platform assessment of balance that manipulates vision, proprioception and vestibular inputs to evaluate postural control. The policy’s coverage distinctions reflect the evidence base for these tests: ENG/VNG are considered medically necessary, while tests such as VEMP, vHIT and CDP are considered investigational where evidence is insufficient to demonstrate diagnostic accuracy or improved outcomes.

Test definitions and short descriptions

Computerized Dynamic Posturography (CDP)

DefinitionComputerized dynamic posturography (CDP) is a diagnostic moving-platform test that assesses balance and postural control by manipulating vision, proprioception, and vestibular inputs to identify disequilibrium from labyrinthine, oculovestibular, or somatosensory pathway dysfunction.

Also known asMoving platform posturography, dynamic posturography, Equitest™.

Clinical purposeUsed to evaluate balance problems potentially caused by peripheral vestibular or oculovestibular dysfunction and to assess progress during rehabilitation for balance and postural deficits.

Test componentsIncludes sensory organization, motor control, and adaptation testing to challenge visual, vestibular, and proprioceptive contributions to standing balance.

Electronystagmography (ENG)

Definition

Policy Summary

PayerIndependent Health

PolicyVestibular Dysfunction Evaluation

Policy CodePolicy M2018031403

Change TypeClarified coverage and added investigational determinations

Effective DateMay 1, 2018

Next Review Date

Key ActionObtain pre-authorization for CDP, VEMP, and vestibular rehabilitation using virtual reality devices before scheduling services.

SourceLink

On This Page

Documentation Required

Clinical and Technical Documentation Required

When seeking authorization or submitting for retro-review, include complete clinical and technical documentation: concise clinical history describing vestibular symptoms (e.g., dizziness, vertigo, imbalance), relevant prior treatments and response, results of physical and neurologic examination (including bedside vestibular tests such as Dix-Hallpike or Head Impulse Test), and rationale for the requested test or therapy. For diagnostic testing, provide documentation of technical adequacy (test type, equipment used, quality of recordings/images, and interpretation). For VEMP and vHIT include documentation of test method (electrode placement, stimulus parameters, camera/goggle quality) and whether results were interpretable. For vestibular rehabilitation with virtual reality, provide treatment plan, device used, session frequency/duration, and functional goals.

Clinical history and presenting symptoms (dizziness, vertigo, disequilibrium)
Prior treatments and responses
Physical and neurologic exam findings (including bedside vestibular maneuvers)
Specific test details and technical adequacy (equipment, recording quality, parameters)
Interpretation of test results and clinical rationale for testing or VR-based rehab
For VR rehab: device identified, treatment plan, session frequency/duration, and functional goals

Note

Operational pre-authorization note

Operational note: for services that do not require pre-authorization, the documented clinical criteria described elsewhere in the policy will be used for retroactive medical necessity review. If retro-review finds services do not meet criteria, payment may be adjusted per payer policy.

Electronystagmography (ENG) uses surface electrodes to record eye movements and quantify both spontaneous and induced nystagmus.

Clinical useEmployed as part of the vestibular evaluation for patients with dizziness, vertigo, or imbalance, often alongside imaging and other vestibular tests.

Relation to VNGENG is an established technique; videonystagmography (VNG) is an alternative method that records eye movements using video cameras.

Vestibular Evoked Myogenic Potential (VEMP)

DefinitionVestibular evoked myogenic potential (VEMP) measures vestibular-dependent reflexes originating from the otolith organs (saccule and utricle) by recording muscle responses to sound or skull vibration using surface electrodes.

Stimulus and recordingShort bursts of loud air-conducted sound or bone-conducted skull vibration are used to stimulate the vestibular organs while surface electrodes record activity from cervical or extraocular muscles.

Evidence noteClinical guidelines indicate insufficient evidence to determine VEMP's accuracy for identifying specific otolith function or certain vestibular diagnoses.

Video Head Impulse Test (vHIT)

DefinitionVideo Head Impulse Test (vHIT) evaluates vestibulo-ocular reflex function by monitoring eye movements with a high-speed camera mounted on tight-fitting goggles while the clinician delivers small, rapid head impulses.

Technical requirementsUses head-mounted cameras and head velocity sensors with software to objectively measure head and eye velocities; requires high-quality, unobstructed pupil imaging for valid measures.

Contrast to other testsAssesses reflex function at high head velocities, complementary to slower-speed rotational testing and the bedside head impulse test.

Videonystagmography (VNG)

DefinitionVideonystagmography (VNG) uses video cameras to record and quantify both spontaneous and induced nystagmus by capturing eye movements on camera.

Relationship to ENGVNG is an alternative to ENG for recording and quantifying eye movements during vestibular testing.

Clinical roleUsed in the vestibular diagnostic battery alongside other tests (e.g., Dix–Hallpike, calorics) to evaluate dizziness and vertigo.