CG-MED-94 Vestibular Function Testing

This policy addresses vestibular function testing (electronystagmography, videonystagmography, caloric testing, rotational chair testing) and vestibular-evoked myogenic potential (VEMP) testing. Coverage is medically necessary for vestibular testing when the patient has symptoms of a vestibular disorder (e.g., dizziness, vertigo, imbalance) and a diagnosis cannot be established by clinical exam; VEMP is medically necessary only to evaluate suspected superior canal dehiscence syndrome when neuroimaging is inconclusive. Testing (including VEMP) is not covered when these criteria are not met, and VEMP specifically is not covered for suspected benign positional vertigo, Meniere disease, or labyrinthitis.

"Vestibular function testing (that is, electronystagmography, videonystagmography, caloric testing, or rotational chair testing) is consideredmedically necessaryunder the following circumstances:"