E71.50 — Peroxisomal disorder, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Refer to LCD L34975 for the detailed reasonable and necessary clinical criteria and documentation required to support coverage of NEPs.
- Use CPT codes 95925, 95926, 95927, 95928, 95929, 95938, and 95939 for Somatosensory Evoked Potentials/Responses (SEPs/SERs).
- Use CPT codes 92651, 92652, and 92653 for Brainstem Auditory Evoked Potentials/Responses (BAEPs/BAERs).
- Use CPT code 95930 for Visual Evoked Potentials/Responses (VEPs/VERs).
Key Coverage Criteria
- Neurophysiology Evoked Potentials (NEPs) — including Somatosensory Evoked Potentials (SEPs), Brainstem Auditory Evoked Potentials (BAEPs/BAERs), and Visual Evoked Potentials (VEPs/VERs) — are covered when determined to be reasonable and necessary in accordance with LCD L34975.
- Perform SEPs/SERs in the assessment of comatose patients when testing of somatosensory pathways is indicated.
- Use VEPs/VERs to detect optic neuritis at an early or subclinical stage.
- Perform SEPs/SERs in evaluation of myoclonus to assess somatosensory pathway involvement.
- Perform SEPs/SERs for evaluation after spinal cord trauma when central somatosensory pathway injury is suspected.
- Perform SEPs/SERs for degenerative, non‑traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy) when central somatosensory pathway involvement is suspected.
4 Active Policies
A56773 — Billing and Coding: Neurophysiology Evoked Potentials (NEPs)
J12
L34975 — Neurophysiology Evoked Potentials (NEPs)
J12
CIGNA-0136 — Infant Nutritional Formula - (0136)
CIGNA-CPG129 — Electrodiagnostic Testing (EMG/NCV) - (CPG129)
Related Codes
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