LCD L34537

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1861(ll)(3) and (ll)(4)(B) defines Speech-Language Pathology Services and Audiology Services.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.3 Audiology Services and §80.3.1 Definition of Qualified Audiologist

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.2.3 Requesting Additional Documentation During Prepayment and Postpayment review

42 CFR §410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

42 CFR §410.33 Independent diagnostic testing facility

HCFA Ruling 95-1 is binding on providers, contractors, appeal levels, and an Administrative Law Judge. Ruling 95-1 describes limitations on the usage of limitation of liability (SSA, §1879).

Indications and Limitations of Coverage

This policy addresses diagnostic testing of the vestibular system. Vestibular tests are tests of function, designed to identify a potential cause of balance problems. Their purpose is to determine if there is a problem with the vestibular portion of the brainstem and inner ear. Studies have documented that in appropriate clinical settings, vestibular tests are more accurate than clinical examination in identifying these disorders. The appropriate clinical setting is described in this policy, including careful evaluation of the patient, rationale for ordering high quality tests, clear communication between the treating physician, consulting physician, and audiologist, interpretation in light of the patient's case, and a plan for use of the results in the patient's care. Diagnostic tests are not payable by Medicare unless directly used in the patient's care.

Vestibular function testing (VFT) is covered for the purpose of determining the appropriate medical or surgical treatment of disorders in the vestibular system. Other causes of balance problems can be found in other systems including the senses of sight and touch, proprioception, muscle movement, and from the integration of sensory input by the cerebellum. Causes of balance problems can also include low blood pressure (BP), including postural hypotension, asymmetrical gait due to pain, poor vision, poorly fitting shoes, lack of concentration on safety in the immediate environment, anxiety, and others.

Vestibular Testing

When a patient presents with complaints of balance problems, a thorough history should be taken, a complete physical examination should be conducted and a thorough review of medications should be completed. These expected medical activities can often elicit a likely cause of the problem. A complete picture of the patient is necessary before testing decisions can be made. The tests that would identify a common cause of balance problems should be conducted first, with progression in testing toward the least common cause of balance problems.

For example, an electrocardiogram (ECG) may show bradycardias or heartblocks. A series of BP checks may show a pattern related to medication intake time. The patient may be taking more (or less) medication than ordered because he/she didn’t understand the dosing instructions.

If the provider sees or suspects a cause that would warrant a referral to a specialist, a referral would be expected. For example, if an ECG showed cardiac rhythm abnormalities, a referral to Cardiology would be expected. Any neurological findings on physical examination could warrant a referral to a neurologist, neurosurgeon, neurotologist, or similar specialist. Since vestibular disorders are common causes of vertigo, imbalance and falling, referral to specialists of these disorders may lead to more rapid diagnosis and most appropriate use of vestibular testing.

Treating Physician / Billing Provider

As noted above, VFTs are covered by Medicare only if they are clinically necessary to diagnose vestibular disorders. A test is clinically necessary if there is (A) appropriate evaluation and justification prior to the test and (B) the results are used to manage the patient. A written order is required from a physician who is treating the beneficiary; that is, the physician who is (A) furnishing a consultation or (B) treating a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. The treating physician has a relationship with the beneficiary prior to the performance of the testing and is treating the beneficiary for a specific medical problem for which the tests are being ordered.

Scope of Practice

Dizziness may support the medical necessity for hearing tests in the initial otolaryngologic evaluation of patients in whom general medical causes (anemia, cardiovascular, metabolic, etc.) have been excluded. However, since dizziness is a vague complaint, a diagnosis of dizziness alone does not qualify for coverage for VFT. There must be sufficient evaluation of the patient that vestibular testing is likely to contribute directly to the patient's therapy. In those instances, full audiometric evaluation can be a critical part of a full vestibular evaluation. The patient's record should clearly document these circumstances.

When the medical conditions requiring medical or surgical treatment are already known by the physician, or are not under consideration, and the diagnostic services are performed only to determine the need for or the appropriate type of hearing aid, the services are statutorily excluded from Medicare coverage whether performed by a physician or nonphysician.

Hearing Testing

Standard hearing tests are not addressed in this policy. However, when a hearing test is ordered as a basis from which to decide to conduct vestibular testing (the provider may suspect a vestibular problem but wants to rule out a pathology other than normal age-related hearing loss), the hearing test will be covered.

Diagnostic audiologic testing (including hearing and balance assessment services) is covered when performed by a physician or a qualified audiologist. An individual with a master's or doctoral degree in audiology and is licensed as such by the relevant State is considered to be a qualified audiologist. In addition to required licensure, audiologists are encouraged to obtain a Certificate of Clinical Competence from the American Speech-Language-Hearing Association (ASHA).

In addition to the above qualification criteria, the following requirements must also be met:

•

The testing is ordered by a physician to obtain additional information to evaluate the need for or appropriate type of medical or surgical treatment for a hearing deficit or a medical problem; and

• The name of the physician ordering the testing is reported on the audiologist’s claim (for example, testing performed by the audiologist to measure a hearing deficit or to identify the factors responsible for the deficit is covered when such services enable the physician to determine whether otologic surgery is indicated).

Basic Audiometry: Adequate testing requires an audiometer (device for presenting sounds to the patient at precisely controlled intensity), a sound-proof environment, a physician/audiologist, and a cooperative patient.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements:

Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.

The patient’s record must document a balance problem which required further evaluation to determine the appropriate medical or surgical treatment.

Services are excluded when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for or the appropriate type of a hearing aid. Diagnostic services performed by a qualified audiologist and meeting the above requirements are payable as “other diagnostic tests”. Medicare coverage for these services is determined by the reason the tests were performed, rather than the diagnosis or the patient's condition.

Utilization

It is very rarely necessary to conduct the entire battery of tests. In particular, as discussed in the Coverage Indications, Limitations and/or Medical Necessity section, previous workup, history, and exam will be carefully scrutinized to ensure that exhaustive test batteries are justified and appropriate to the patient’s history and symptoms. It is not necessary to conduct additional tests once the problem and its diagnosis have been determined or identified.

Most of the tests for vestibular function are conducted once per day. Repeat testing is only covered when medically necessary to assess specific medical or surgical treatments. In this instance, medically necessary means, for example, if symptoms are unchanged or a treatment completely resolves symptoms, elaborate repeat testing is not usually medically necessary to confirm this.

Repeat testing on a regular basis, in the absence of the resumption of symptoms, is not warranted. A few conditions may require testing on multiple days due to variably acute symptoms, such as benign positional vertigo which varies with inner ear canal stones.

Bibliography

Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology Head and Neck Surg. 2008;139(5 suppl 4):S47-S81.

Desmond AL. Vestibular Function: Evaluation and Treatment. New York, NY: Thieme Medical Publishers, Inc; 2004:65-111.

Goebel JA. Practical Management of the Dizzy Patient. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

Strupp M, Brandt T. Diagnosis and treatment of vertigo and dizziness. Dtsch Arztebl Int. 2008;105(10):173-180.

Vestibular Disorders Association. Vestibular Disorders: An Overview. Accessed on 8/3/2021.