E2120, Pulse generator system for tympanic treatment of inner ear endolymphatic fluid
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Diagnosis of BPPV documented by a positive Hallpike (Dix-Hallpike) maneuver: 'The Hallpike maneuver ... when positive, is diagnostic of BPPV.'
- For use of particle repositioning maneuvers / CRP: documentation of posterior semicircular canal BPPV or other identified canal involvement and clinical response (treatment usually single session; additional 1–2 sessions over 2 weeks may be necessary).
- Vestibular rehabilitation should be documented as performed by a licensed occupational or physical therapist: 'Vestibular rehabilitation should be performed by a licensed occupational or physical therapist.'
- For Meniett/transtympanic micropressure: documentation that a tympanostomy tube has been inserted and that device is used according to physician prescription and training: 'After a standard ventilation tube is inserted into the tympanum ... After prescription and training by a physician, patients can treat themselves with the device at home.'
Key Coverage Criteria
- Diagnosis and evaluation of chronic vertigo or Ménière's disease using caloric vestibular testing.
- Diagnosis and evaluation of chronic vertigo or Ménière's disease using dynamic (head‑shaking) visual acuity testing.
- Diagnosis and evaluation of chronic vertigo or Ménière's disease using head impulse / head thrust test.
- Diagnosis and evaluation of chronic vertigo or Ménière's disease using optokinetic nystagmus testing.
- Diagnosis and evaluation of chronic vertigo or Ménière's disease using spontaneous nystagmus testing.
- Electronystagmography (ENG) is used to assess patients with vestibular disorders (e.g., dizziness, vertigo, or balance dysfunction). It provides objective testing of the oculomotor and vestibular systems.
6 Active Policies
AETNA-CPB-0238, Chronic Vertigo
AETNA-CPB-0514, Meniere's Disease and Related Disorders: Surgery
BCBSIL-ADM1001.036, Medical Policies Moving to MCG Guidelines
BCBSMT-ADM1001.036, Medical Policies Moving to MCG Guidelines
BCBSNM-ADM1001.036, Medical Policies Moving to MCG Guidelines
Related Codes
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