H91.23 — Sudden idiopathic hearing loss, bilateral
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.
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- G71.21 | Nemaline myopathy
- G83.0 | Diplegia of upper limbs
- H44.19 | Other endophthalmitis
12 Active Policies
L34975 — Neurophysiology Evoked Potentials (NEPs)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
A56773 — Billing and Coding: Neurophysiology Evoked Potentials (NEPs)
J12
A57434 — Billing and Coding: Vestibular and Audiologic Function Studies
J12
ANTHEM-CG-SURG-82
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