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DESCRIPTIONWhen the body is exposed to a light, a sound, or a touch, the brain responds by making certain types of brain waves. These waves are picked up by wires attached to the skin, then they are analyzed by a computer. Finally, a physician interprets the brain wave pattern. These waves are also called evoked potentials. Waves caused by lights are called visual evoked potentials. Such responses may indicate optic nerve involvement; i.e., by multiple sclerosis. Waves caused by sounds are called auditory evoked potentials. These may be used to differentiate sensory from neural hearing loss. Waves caused by touch are called somatosensory evoked potentials. These responses may be used to diagnose physiologic changes at various levels of the central nervous system.
With certain types of disease, the brain waves caused by sights, sounds, and touch, are abnormal (either the waves happen too late after the sound or light, or the waves are smaller than normal).
One theory suggests that measuring sensory evoked potentials might help the surgeon avoid damaging the nerve system. See separate policy Intraoperative Neurophysiologic Monitoring (sensory evoked potentials, motor-evoked potentials, EEG monitoring).
POLICYWhen services are medically necessary:
Visual Evoked Potentials (CPT 95930)
Auditory Evoked Potentials (CPT 92585, 92586)
Somatosensory Evoked Potentials (CPT 95925, 95926, 95927, 95938)
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY8/1997: Approved by Medical Policy Advisory Committee (MPAC)
3/26/2002: Policy reformatted with tables, ICD-9 procedure code 95.46 deleted, non-covered codes added, fourth and/or fifth digit added to 240, 781.9, 192, 210, 225, 230, 231, 235, 237, 238, 239, 250.2, 250.3, 389, 952, 800, and 240.
8/2002: Reviewed by MPAC; policy title "Sensory Evoked Potentials" renamed "Diagnostic Uses of Sensory Evoked Potentials (SEPs), separate policy for Intraoperative Neurophysiologic Monitoring (sensory evoked potentials, motor-evoked potentials, EEG monitoring)
1/20/2003: CPT code 92585 description updated
3/10/2004: Code Reference section updated, ICD-9 diagnosis code 333.0 fourth digit added Auditory Evoked Potentials, ICD-9 diagnosis codes 345.3, 436, 780.39 deleted Auditory Evoked Potentials, ICD-9 diagnosis codes 070.1, 070.20-070.23, 070.41-070.49, 070.6, 780.02 added Auditory Evoked Potentials, ICD-9 diagnosis code 240.0-240.9 expanded to 240.0-250.13 Somatosensory Evoked Potentials not medically necessary, ICD-9 diagnosis 250.40-250.93, 251.1-279.8 added Somatosensory Evoked Potentials not medically necessary
10/20/2004: Code Reference section updated, ICD-9 diagnosis code range 070.20-070.23, 070.41-070.49, 250.20-250.23, 250.30-250.33, 389.0-389.9, 952.00-952.9, 240.0-250.13, 250.40-250.93 listed separately, ICD-9 diagnosis code 379.54, 386.00, 386.01, 386.02, 386.03, 386.04, 744.00, 744.01, 744.02, 744.03, 744.04, 744.05, 744.09 added covered codes
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/9/2008: Description clarified for sensory and neural hearing loss testing for Auditory Evoked Potentials. "For children under age 5, to determine the type and degree of hearing problems or to determine the developed status of nerves", removed from the Auditory Evoked Potentials POLICY section for sensory and neural hearing loss. ICD-9 codes 389.05, 389.06, 389.15, and 389.16 added to covered codes for Auditory Evoked Potentials.
9/16/2008: Annual ICD-9 updates effective 10-1-2008 applied
02/18/2011: Added the following ICD-9 codes as covered for CPT codes 92585 and 92586: 386.10, 386.11, 386.12, 386.19.
03/08/2013: Policy reviewed; no changes.
08/28/2015: Code Reference section updated for ICD-10. Added ICD-9 diagnosis code range 173.20 – 173.29 and removed ICD-9 diagnosis codes 173.2, 192.0, 147.2, 197.3, 198.4, 198.89, 210.7, 225.1, 230.0, 235.1, 237.9, 239.0, 239.2, 239.7, 386.10, 386.11, 386.12, and 386.19.
03/15/2016: Policy updated to add CPT code 95938 as a covered code.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)HCFA - Medicare Program. National Coverage Decisions. Federal Register. Vol. 54; No. 160; 8/21/89.
Hayes Medical Technology Directory
March, 1988 TEC (Technology Evaluation Center) Assessment of Diagnostic Uses of Sensory Evoked Potentials (SEPs)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.