Subject:
Visual-Evoked Potential (VEP)/Visual-Evoked Response (VER)
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Visual-evoked potential (VEP), also known as visual-evoked response (VER) is the result of stimulation of the retina and optic nerve either by an alternating checkerboard pattern or by a flash method (brief flashes of light with no discernable pattern or contour) causing measurable electrical activity in response to the visual stimuli. The VEP measures the time that it takes for a visual stimulus to travel from the eye to the occipital visual cortex. Responses are recorded through electrodes placed on the scalp over the visual cortex and are observed as a reading on an electroencephalogram (EEG). The light-evoked signal is small in amplitude and hidden within the normal electroencephalographic (EEG) signal. It is amplified by repetitive stimulation, separated from the background EEG readings, and averaged. A characteristic waveform is produced. The VEP characteristically shows an increase in P100 latency of the involved side. The signal will be reduced by damage anywhere along the pathway including the eye, retina, the optic nerve, optic radiations, and occipital cortex. However, abnormalities of flash and/or pattern VEPs are generally nonspecific with regard to the underlying etiology and pathology.
Pupillary size, gender, and age all affect VEP. It may also be affected by measures related to technique including check size, luminance, field size, etc. Certain drugs (e.g., carbamazepine) prolong VEP. Because VEP is primarily a function of central visual function, peripheral visual loss might be overlooked by VEP testing. VEP is most useful for testing optic nerve function and detecting demyelization disease, optic neuritis, ischemic optic neuropathy, compressive optic neuropathy and amblyopia and less useful in assessing post-chiasmatic disorders.
Related Policies
- Intraoperative Neurophysiologic Monitoring (Policy #114 in the Surgery Section)
Policy:
[NOTE: This policy does not apply to intraoperative neurophysiologic monitoring. Please refer to Policy #114 in the Surgery Section.
NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
A. Visual-evoked potential (VEP) or visual-evoked response (VER) testing is considered medically necessary for the following indications when medical documentation supports the medical necessity for VEP/VER testing including, but not limited to, relevant medical history, physical exam and results of pertinent diagnostic tests including visual acuity:
1. To confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive.
2. To detect optic neuritis at an early, subclinical stage.
3. To evaluate diseases of the optic nerve, such as:
a. Ischemic optic neuropathy
b. Pseudotumor cerebri
c. Toxic amblyopias
d. Nutritional amblyopias
e. Neoplasms compressing the anterior visual pathways
f. Optic nerve injury or atrophy
g. Hysterical blindness (to rule out)
4. To evaluate signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons, etc)
5. To evaluate the vision of an infant or toddler when clinical evaluation by indirect visual acuity testing, refraction, ocular health assessment, or forced-choice preferential looking with the Teller acuity cards indicates a problem with the infant's or toddler's visual acuity.
B. VEP/VER testing is considered investigational for all other indications including, but not limited to, the following situations:
- Screening or routine testing of infants, children, and adults
- Detection of glaucoma
- Detection of cataracts
- Evaluation of the visual pathways in neurodegenerative diseases (other than multiple sclerosis).
Medicare Coverage:
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that Visual Evoked Potentials or Responses (VEPs/VERs) (CPT code 95930) is covered for adults when LCD L34975 criteria are met. For eligibility and coverage, refer to Novitas Solutions Inc, Local Coverage Determination (LCD): Neurophysiology Evoked Potentials (NEPs) L34975. Available at: Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34975&ver=32&Date=10%2f01%2f2016&DocID=L34975&bc=iAAAABAAAAAAAA%3d%3d&.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
Fide-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
[INFORMATIONAL NOTE: Evidence-based guidelines from leading medical professional organizations and public health agencies have not recommended VEP screening of infants, children and adults. They include, but are not limited to, the following organizations and agencies:
- American Association for Pediatric Ophthalmology and Strabismus
- American Academy of Ophthalmology
- The American Academy of Pediatrics (AAP)
- AAP, AAPOS and AAO Hoskins Center for Quality Eye Care
- American Optometric Clinical Guideline
- U.S. Preventive Services Task Force
Screening is generally defined as testing for disease in an individual that appears healthy with the goal of discovering undiagnosed disease. Various screening tests that are feasible in primary care are used to identify visual impairment among children. These tests include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors. In the preverbal child, visual acuity may be assessed by the ability to fix and follow, fixation preference, or objection to occlusion of either eye. Eye examination by the primary care physician should include assessment of the red reflex (Bruckner testing), leukocoria, photophobia, extraocular movements, strabismus, nystagmus, and visual acuity. In the verbal child, visual acuity is assesses by Snellen testing. The American Academy of Pediatrics recommends that children found to have an ocular abnormality or who fail a vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.
VEP testing is not necessary in routine clinical practice, but may be used in special circumstances such as when the office visual function test fails to demonstrate visual function but other clinical findings suggest the child can see. VEP has also been used to assess potential for vision in a child prior to undergoing complex eye surgery to restore vision or in cases of total cataracts to assess the function of the visual pathway.
CLINICAL INPUT
This policy was reviewed by a board certified ophthalmologist. Input received was consistent with the policy. The reviewer added that VEP is indicated to assess or confirm an optic neuropathy or to assess a visual tract abnormality (e.g. optic neuritis, optic nerve tumor, drug toxicity) after a complete physical exam including visual examination by a qualified pediatric ophthalmologist, neuro-ophthalmologist or neurologist is completed and an abnormal testing result was found.
ONGOING AND UNPUBLISHED CLINICAL TRIALS
A study at Mayo Clinic for comparison of standard visually evoked potential (VEP) recording and a portable VEP system (Vivonics INC. portable VEP system) is currently recruiting.
Study inclusion criteria is as follows:
≥13 years, and able to provide informed consent
Under evaluation or management of suspected concussion / Traumatic Brain Injury (TBI)
No alcohol within 48 hours of testing
Corrected visual acuity of 0.00 logMAR (20/20) confirmed with Snellen chart
Control Group
≥13 years, and able to provide informed consent
No acute concussion / TBI history
No alcohol within 48 hours of testing
Corrected visual acuity of 0.00 logMAR (20/20) confirmed with Snellen chart
Exclusion Criteria:
Inability to tolerate the visual stimulus
History of seizures, stroke
Strabismus, amblyopia
History of degenerative neurological condition
Vivonics Inc. is also developing a VEP monitor for use in military field hospitals which treat individuals with traumatic brain injuries. Vivonics' portable VEP is said to integrate the entire VEP test into a single portable device used with a mobile app that is paired with a phone or tablet. The portable VEP monitor is a head-worn unit with on-board embedded electronics and a diagnostic software application to perform several tests related to traumatic brain injury. This product is not FDA currently approved.
A search of clinical trials.gov found a lack of studies on VEP outside of the surgery realm. One study was found comparing Diopsys vision testing system to optical coherence tomography (OCT) for glaucoma diagnosis. The aim of this study was to evaluate the ability of the NOVA-DN VEP protocol and Corda parameters to discriminate between healthy eyes and eyes with early to moderate glaucomatous visual field loss. The study was performed from September 2011 to completion in December 2013. No study results were posted as of July 18, 2017 when ClinicalTrials.gov processed this record.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Visual-Evoked Potential (VEP)/Visual-Evoked Response (VER)
Visual-Evoked Response (VER)/Visual-Evoked Potential (VEP)
VEP (Visual-Evoked Potential)
VER (Visual-Evoked Response)
References:
1. AAP, AAPOS and AAO Hoskins Center for Quality Eye Care. Screening Examination of Premature Infants for Retinopathy of Prematurity. American Academy of Ophthalmology. 2013.
2. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy Of Ophthalmology Policy Statement: Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children: Eye Examination in Infants, Children, and Young Adults by Pediatricians. Pediatrics Vol: 111(4) April 2003.
3. American Academy of Pediatrics, Section on Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, American Association of Certified Orthoptists. Pediatrics Dec: 122 (6):1440-4.
4. American Academy of Pediatrics. Section on Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology; American Association of Certified Orthoptists. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics. Policy Statement 2016.
5. American Academy of Ophthalmology. Preferred Practice Pattern Guidelines: Comprehensive Adult Medical Eye Evaluation. San Francisco: American Acad of Ophthalmology; 2010. Available at: http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=64e9df91-dd10-4317-8142-6a87eee7f517.
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14. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD):Neurophysiology Evoked Potentials (NEPs) (L34975) effective 10/01/16. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34975&ver=32&Date=10%2f01%2f2016&DocID=L34975&bc=iAAAABAAAAAAAA%3d%3d&.
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39. Matta NS, Arnold RW, Singman EL, Silbert DI. Comparison between the plusoptiX and MTI Photoscreeners. Arch Ophthalmol 2009; 127:1591.
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41. Morad Y, Werker E, Nemet P. Visual acuity tests using chart, line, and single optotype in healthy and amblyopic children. J AAPOS 1999; 3:94.
42. Moyer VA, MD, MPH; and U.S. Preventive Services Task Force Annals of Medicine. Screening for Glaucoma: U.S. Preventive Services Task Force Recommendation Statement., revised OCT 01, 2013
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Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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