Printer Friendly Version
Printer Friendly Version
Printer Friendly Version
L.7.01.401
When 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 .
When services are medically necessary:
Visual Evoked Potentials (CPT 95930)
Code Number | Description | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
340 | Diagnosis and monitoring of multiple sclerosis (MS), acute or chronic phases | G35, G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D | Multiple sclerosis (G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D New 10/01/2025) (G35 Deleted 09/30/2025) |
368.40, 368.43, 368.44, 368.46, 368.47 | Localizing the cause of a visual field defect, not explained by lesions seen on CT or MRI, metabolic disorders, or infectious diseases | H53.40, H53.431 - H53.439, H53.451 - H53.459, H53.461 - H53.469, H53.47 | Visual field defects (code ranges) |
Auditory Evoked Potentials (CPT 92650, 92651, 92652, 92653)
Code Number | Description | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
240.0 - 279.9 | Evaluate brainstem function in acquired metabolic disorders | E00.0 - E35, E40 - E71.548, E72.10 - E74.9, E75.21, E75.22, E75.240 - E75.249, E75.3 -E78.70, E78.79 -E78.9, E79.1 - E83.19, E83.30 - E88.9, E89.1 - E89.6, E79.89, E88.810 | Endocrine, nutritional and metabolic diseases (code range) |
191.7, 198.3, 225.0, 237.5, 239.6 | Assess recovery of brainstem function after a lesion compressing the brainstem has been surgically removed | C71.7 | Malignant neoplasm of brain stem |
C79.31 | Secondary malignant neoplasm of brain | ||
D33.0 - D33.2 | Benign neoplasm of brain (code range) | ||
D43.0 - D43.4 | Neoplasm of uncertain behavior of brain (code range) | ||
D49.6 | Neoplasm of unspecified behavior of brain | ||
781.99, 436 | Localizing the cause of a neurologic deficit seen on exam, not explained by lesions seen on CT or MRI | I67.89 | Other cerebrovascular disease |
I67.858 | Other hereditary cerebrovascular disease | ||
R29.818, R29.898 | Other symptoms and signs involving the nervous and musculoskeletal system | ||
R29.90 - R29.91 | Unspecified symptoms and signs involving the nervous and musculoskeletal system (code range) | ||
340, 341.8, 333.0 | Diagnosis and monitoring of demyelinating and degenerative diseases affecting the brain stem (MS, central pontine myelinolysis, olivopontocerbellar degeneration and others) | G23.0 - G23.9, G23.3 | Other degenerative disease of basal ganglia (code range) |
G35, G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D | Multiple sclerosis (G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D New 10/01/2025) (G35 Deleted 09/30/2025) | ||
G37.1, G37.2 | Other demyelinating diseases of central nervous system | ||
G37.81 | Myelin oligodendrocyte glycoprotein antibody disease | ||
G37.89 | Other specified demyelinating diseases of central nervous system | ||
173.20-173.29 160.1, 198.2, 212.0, 216.2, 231.8, 232.2, 235.9, 238.2, 239.1 | Diagnosis of lesions in the auditory system | C30.1 | Malignant neoplasm of middle ear |
C44.201 - C44.299 | Other and unspecified malignant neoplasm of skin of ear and external auricular canal (code range) | ||
C79.2 | Secondary malignant neoplasm of skin | ||
D02.3 | Carcinoma in situ of other parts of respiratory system | ||
D04.20 - D04.22 | Carcinoma in situ of skin of ear and external auricular canal (code range) | ||
D14.0 | Benign neoplasm of middle ear, nasal cavity and accessory sinuses | ||
D22.20 - D22.22 | Melanocytic nevi of ear and external auricular canal (code range) | ||
D23.20 - D23.22 | Other benign neoplasm of skin of ear and external auricular canal | ||
D38.5 | Neoplasm of uncertain behavior of other respiratory organs | ||
D38.6 | Neoplasm of uncertain behavior of respiratory organ, unspecified | ||
D48.5 | Neoplasm of uncertain behavior of skin | ||
D49.1 | Neoplasm of unspecified behavior respiratory system | ||
070.0, 070.20, 070.21, 070.22, 070.23, 070.41, 070.42, 070.43, 070.44, 070.49, 070.6, 250.20, 249.20, 249.21, 249.30, 249.31, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 251.0, 348.81 – 348.89 , 572.2, 779.2, 780.01, 780.02 | Evaluation of the irreversibility of coma or brain death, along with an EEG | B15.0 | Hepatitis A with hepatic coma |
B16.0, B16.2 | Hepatitis B | ||
B17.0, B17.11, B17.2, B17.8 | Other acute viral hepatitis | ||
B18.0, B18.1, B18.2 | Chronic viral hepatitis | ||
B19.0, B19.11 | Unspecified viral hepatitis | ||
E03.5 | Myxedema coma | ||
E08.00- E08.01, E08.01 and E08.65, E08.11, E08.11 and E09.65, E08.641, E08.65 and E09.01 | Diabetes mellitus due to underlying condition (code range and codes) | ||
E09.00, E09.01, E09.11, E09.11 and E09.65, E09.641 | Drug or chemical induced diabetes mellitus | ||
E10.11, E10.11 and E10.65 E10.641, E10.65 and E10.69, E10.69 | Type 1 diabetes mellitus | ||
E11.00, E11.00 and E11.65, E11.01, E11.01 and 11.65, E11.641 | Type 2 diabetes mellitus | ||
E13.00, E13.01, E13.11, E13.641 | Other specified diabetes mellitus | ||
E15 | Nondiabetic hypoglycemic coma | ||
G93.81 - G93.89 | Other specified disorders of brain (code range) | ||
K70.41, K71.11, K72.01, K72.11, K72.90, K72.91 | Diseases of liver | ||
K76.82 | Hepatic encephalopathy | ||
P91.0, P91.1, P91.3, P91.4, P91.5 | Other disturbances of cerebral status of newborn | ||
P91.821, P91.822, P91.823, P91.829 | Neonatal cerebral infarction | ||
R40.2A,R40.20, R40.2110 - R40.2114, R40.2120 - R40.2124, R40.2210 - R40.2214, R40.2220 - R40.2224, R40.2310 - R40.2314, R40.2320 - R40.2324, R40.2340 - R40.2344, R40.4 | Coma (code ranges) | ||
379.54, 386.00, 386.01, 386.02, 386.03, 386.04, 388.12, 389.00, 389.01, 389.02, 389.03, 389.04, 389.05, 389.06, 389.08, 389.10, 389.11, 389.12, 389.13, 389.14, 389.15, 389.16, 389.17, 389.18, 389.20, 389.21, 389.22, 389.7, 389.8, 389.9, 744.00, 744.01, 744.02, 744.03, 744.04, 744.05, 744.09 | Differentiate sensory from neural hearing loss | H55.09 | Other forms of nystagmus |
H81.01 - H81.09 | Meniere's disease (code range) | ||
H83.3X1 - H83.3X9 | Noise effect on inner ear (code range) | ||
H90.0 - H90.8 | Conductive and sensorineural hearing loss (code range) | ||
H91.01 - H91.09, H91.8X1 - H91.8X9, H91.90 - H91.93 | Other and unspecified hearing loss (code ranges) | ||
Q16.0 - Q16.9 | Congenital malformations of ear causing impairment of hearing (code range) |
Somatosensory Evoked Potentials (CPT 95925, 95926, 95927, 95938)
Code Number | Description | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
780.09, 952.00, 952.01, 952.02, 952.03, 952.04, 952.05, 952.06, 952.07, 952.08, 952.09, 952.10, 952.11, 952.12, 952.13, 952.14, 952.15, 952.16, 952.17, 952.18, 952.19, 952.2, 952.3, 952.4, 952.8, 952.9 | To assess any decline which may warrant emergent surgery in unconscious spinal cord injury patients who show specific structural damage to the somatosensory system, and who are candidates for emergency spinal cord surgery | R40.0, R40.1 | Somnolence |
S14.0XXA - S14.159S | Injury of spinal cord at neck level (code range) | ||
S24.0XXA - S24.159S | Injury of spinal cord at thorax level (code range) | ||
S34.01XA - S34.139S, S34.3XXA - S34.3XXS | Injury of lumbar and sacral spinal cord at abdomen, lower back and pelvis level (code ranges) | ||
E75.27 | Pelizaeus-Merzbacher disease | ||
340, 330.0 | Diagnosis and management of specific neurologic diseases which involve the somatosensory system, such as MS and Pelizaeus-Merzbacher disease | E75.23, E75.25, E75.29 | Other sphinogolipidosis |
G35, G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D | Multiple sclerosis (G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D New 10/01/2025) (G35 Deleted 09/30/2025) |
When services are not medically necessary:
Somatosensory Evoked Potentials for the following:
Code Number | Description | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
780.09, 800.0 - 804.9, 959.01 | In unconscious patients with head injuries because these recordings do not change management | R40.0, R40.1 | Somnolence and stupor |
S02.0XXA - S02.42XS; S02.600A - S02.92XS | Fracture of skull and facial bones (code ranges) | ||
S06.330A - S06.339S | Contusion and laceration of cerebrum, unspecified (code range) | ||
S06.360A - S06.369S | Traumatic hemorrhage of cerebrum, unspecified (code range) | ||
S06.4X0A - S06.4X9S | Epidural code range (code range) | ||
S06.5X0A - S06.5X9S | Traumatic subdural hemorrhage (code range) | ||
S06.6X0A - S06.6X9S | Traumatic subarachnoid hemorrhage (code range) | ||
S06.890A - S06.899S | Other specified intracranial injury (code range) | ||
S06.9X0A - S06.9X9S | Unspecified intracranial injury (code range) | ||
S09.10XA - S09.19XS | Other and unspecified injuries of head (code range) | ||
S09.8XXA – S09.8XXS | Other specified injuries of head | ||
S09.90XA – S09.90XS | Unspecified injury of face and head | ||
335.20 | In the diagnosis or management of ALS, because this test does not pinpoint the diagnosis or change management | G12.21 | Amyotrophic lateral sclerosis |
G12.25 | Progressive spinal muscle atrophy | ||
240.0, 240.9, 241.0, 241.1, 241.9, 242.00, 242.01, 242.10, 242.11, 252.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 242.90, 242.91, 243, 244.0, 244.1, 244.2, 244.3, 244.8, 244.9, 245.0, 245.1, 245.2, 245.3, 245.4, 245.8, 245.9, 246.0, 246.1, 246.2, 246.3, 246.8, 246.9, 249.00, 249.01, 249.10, 249.11, 249.40, 249.50, 249.51, 249.60, 249.61, 249.70, 249.71, 249.80, 249.81, 249.90, 249.91, 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 251.1-279.9 | In the diagnosis or management of metabolic disorders, since these recordings are not likely to change patient management | E00.0 – E03.4, E03.8 –E07.1, E07.89, E07.9 | Disorders of thyroid gland (code range) |
E89.0 – E89.6 | Postprocedural hypothryoidsim (Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified) | ||
E08.10, E08.21 - E08.9 | Diabetes mellitus due to underlying condition | ||
E09.10, E09.21 - E09.638, E09.649 – E09.9 | Drug or chemical induced diabetes mellitus | ||
E10.10, E10.21 - E10.9 | Type 1 diabetes mellitus | ||
E11.21 - E11.638, E11.649 – E11.9 | Type 2 diabetes mellitus | ||
E13.10, E13.21 - E13.638, E13.649 – E13.9 | Other specified diabetes mellitus (code range) | ||
E16.0 - E16.9 | Other disorders of glucose regulation and pancreatic internal secretion (code range) | ||
E16.A1, E16.A2, E16.A3 | Hypoglycemia level | ||
E20.0 - E35 | Disorders of other endocrine glands (code range) | ||
E40 - E46 | Malnutrition (code range) | ||
E50.0 - E64.9 | Other nutritional deficiencies (code range) | ||
E65 - E68 | Overweight, obesity, and other hyperalimentation (code range) | ||
E70.0 - E74.9; E75.21, E75.22, E75.240 - E75.249; E75.3 – E75.6, E76.01 – E78.6, E78.70, E78.79, E78.81 – E78.9, E80.0 – E83.19, E83.30- E88.9, E88.810 | Metabolic disorders (code ranges and codes) | ||
H49.811 - H49.819 | Kearns -Syndrome (code range) | ||
M1A.00XA - M1A.09X1, M1A.20X0 – M1A.9XX1 | Chronic gout (code range) | ||
M10.00 - M10.9 | Gout (code range) | ||
M35.9 | Systemic involvement of connective tissue, unspecified | ||
M83.0 - M83.9 | Osteomalacia (code range) | ||
N20.0 | Calculus of kidney | ||
N98.1 | Hyperstimulation of ovaries |
None
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 Mental Health Disorders, 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 medical necessity, “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.
8/1997: 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 L.7.01.401 added. Policy Guidelines updated to add medically necessary definition.
09/29/2017: Policy section updated to add new ICD-10 diagnosis code G12.25 to the not medically necessary codes table for somatosensory evoked potentials. Effective 10/01/2017.
12/22/2017: Code Reference section updated to revise description for CPT code 95930 effective 01/01/2018.
05/24/2018: Medical policy link updated in policy description.
09/25/2018: Code Reference section updated to add new ICD-10 diagnosis code I67.858, effective 10/01/2018.
09/30/2020: Code Reference section updated to add new ICD-10 diagnosis codes P91.821, P91.822, P91.823, and P91.829, effective 10/01/2020.
12/17/2020: Policy and Code Reference sections updated to add new CPT codes 92650, 92651, 92652, and 92653, effective 01/01/2021.
09/30/2022: Policy reviewed. Policy statements unchanged. Policy section updated to add new ICD-10 diagnosis code K76.82, effective 10/01/2022. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to remove deleted CPT codes 92585 and 92586.
09/28/2023: Code Reference section updated to add new ICD-10 diagnosis codes E79.89, E88.810, G23.3, G37.81, G37.89, R40.2A, and E75.27, effective 10/01/2023.
10/17/2023: Policy reviewed; no changes.
10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes E16.A1, E16.A2, and E16.A3. Removed deleted ICD-10 diagnosis code G37.8.
10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D.
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)
This 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.
Code Number | Description | ||
CPT-4 | |||
92650 | Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis | ||
92651 | Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report | ||
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, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs | ||
95926 | Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs | ||
95927 | Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head | ||
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, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs | ||
HCPCS | |||
ICD-9 Procedure | ICD-10 Procedure | ||
89.15 | Other non-operative neurologic function tests | F01Z9JZ | Somatosensory evoked potentials assessment using somatosensory equipment |
F13ZL7Z | Auditory evoked potentials assessment using electrophysiologic equipment | ||
95.23 | Visual evoked potential (VEP) | 4A07X0Z | Measurement of visual activity, external approach |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
Refer to Policy section above |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.