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Medical Policy

Policy Num:       02.007.004
Policy Name:     Somatosensory evoked potential studies visual/auditory
Policy ID:         [2.007.004][Ar L M + P + ][0.00.00]

Last Review: November 10, 2021
Next Review: N/A
Issue: 11: 2021

Related Policies: None

ARCHIVED

Somatosensory evoked potential studies visual/auditory

Popultation Reference No.	Populations	Interventions	Comparators	Outcomes
1	Individuals: Demonstrating abnormality in the functioning of the sensory nervous system in patients with a questionable clinical presentation	Interventions of interest are: studies of evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life Medically necessary
2	Individuals: Needing help to define the anatomical distribution of the disease or condition in question	Interventions of interest are: studies of evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
3	Individuals: That need objective monitoring of changes over time	Interventions of interest are: studies of evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
4	Individuals: Determine the treatment to be instituted and/or evaluate the efficacy of the same.	Interventions of interest are: studies of evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
5	Individuals: Diagnosis and monitoring of multiple sclerosis	Interventions of interest are: Visual evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome.
6	Individuals: Location of the cause of defects in Visual fields, when it is not explained by lesions seen on CT or MRI.	Interventions of interest are: Visual evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
7	Individuals: Diagnosis and monitoring of demyelinating and degenerative diseases affecting brain stem function (multiple sclerosis, myelinolytic pontinocerebral, olivopontocerebellar degeneration, etc.)	Interventions of interest are: Visual evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
8	Individuals: Metabolic disorders or infectious diseases	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
9	Individuals: To assess the functional recovery after surgical removal of lesion(s) which compresses the brain stem.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
10	Individuals: Location of the cause of neurological deficit that is not explainable by identified lesions by CT or MRI	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
11	Individuals: Diagnosis and monitoring of demyelinating and degenerative diseases affecting brain stem function (multiple sclerosis, myelinolytic pontinocerebral, olivopontocerebellar degeneration, etc.)	Diagnosis and monitoring of demyelinating and degenerative diseases affecting brain stem function (multiple sclerosis, myelinolytic pontinocerebral, olivopontocerebellar degeneration, etc.)	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
12	Individuals: Diagnosis of lesions in the auditory system.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
13	Individuals: Along with the EEG, for the evaluation of irreversible coma or brain death.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
14	Individuals: Intraoperative monitoring of brain stem auditory evoked potentials during a procedure of the spinal cord, intracranial or vascular.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
15	Individuals: Confirmation of the diagnosis of acoustic neuroma.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
16	Individuals: Determine of the type and severity of hearing problems or determine the degree of development of the nerves of the auditory system in children under five years of age.	Interventions of interest are: Auditory evoked potentials	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
17	Individuals: To validate and quantify any impairment to justify surgical intervention in patients who are unconscious, who have suffered trauma to the spinal cord and that show structural damage of the somatosensory system and those who are candidates for surgery of the spinal cord.	Interventions of interest are: Somatosensory evoked potential	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
18	Individuals: Intraoperative monitoring during surgery of the vascular, intracranial or spinal cord	Interventions of interest are: Somatosensory evoked potential	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life
19	Individuals: Diagnosis and management of specific neurological conditions that involve somatosensory system, such as multiple sclerosis and Pelizaeus-Merzbacher disease.	Interventions of interest are: Somatosensory evoked potential	Comparators of interest are: Standard of care without somatosensory evoked potentials	Relevant outcomes include: Morbid events Functional outcome. Quality of life

Summary

Evoked potentials are somatosensory stimuli, Visual and/or auditory. The same, when applied activate corresponding anatomical areas, resulting in a cortical potential. Latency, duration, and amplitude of the responses reflect the physiological integrity of the sensory pathways examined.

Objective

The objective of this review is to identify the range of medical conditions where somatosensory evoked potentials has medically necessary indications.

Policy Statements

Triple-S will consider for payment studies of evoked potentials when they are performed with the purpose of:

• Demonstrating abnormality in the functioning of the sensory nervous system in patients with a questionable clinical presentation.

• Help define the anatomical distribution of the disease or condition in question.

• Objectively monitor changes over time.

• Determine the treatment to be instituted and/or evaluate the efficacy of the same.

Indications for its use

a) Visual evoked potentials:

• Diagnosis and monitoring of multiple sclerosis (in acute or chronic phase).

• Location of the cause of defects in Visual fields, when it is not explained by lesions seen on CT or MRI.

• Metabolic disorders or infectious diseases.

b) Auditory evoked potentials:

• Evaluation of function of the brain stem in acquired metabolic disorders.

• To assess the functional recovery after surgical removal of lesion(s) which compresses the brain stem.

• Location of the cause of neurological deficit that is not explainable by identified lesions by CT or MRI.

• Diagnosis and monitoring of demyelinating and degenerative diseases affecting brain stem function (multiple sclerosis, myelinolytic pontinocerebral, olivopontocerebellar degeneration, etc.)

• Diagnosis of lesions in the auditory system.

• Along with the EEG, for the evaluation of irreversible coma or brain death.

• Intraoperative monitoring of brain stem auditory evoked potentials during a procedure of the spinal cord, intracranial or vascular.

• Confirmation of the diagnosis of acoustic neuroma.

• Determine of the type and severity of hearing problems or determine the degree of development of the nerves of the auditory system in children under five years of age.

c) Somatosensory evoked potential:

• To validate and quantify any impairment to justify surgical intervention in patients who are unconscious, who have suffered trauma to the spinal cord and that show structural damage of the somatosensory system and those who are candidates for surgery of the spinal cord.

• Intraoperative monitoring during surgery of the vascular, intracranial or spinal cord.

• Diagnosis and management of specific neurological conditions that involve somatosensory system, such as multiple sclerosis and Pelizaeus-Merzbacher disease.

Triple-S shall not consider for payment studies done in the following situations:

a) Intraoperative:

1. Visual evoked potentials

2. Motor evoked potentials

b) Auditory evoked potentials for the determination of gestational age during pregnancy.

c) Somatosensory evoked potential:

1. In patients with craniocerebral trauma - not in coma, because it does not alter the management of patients.

2. In the diagnosis or management of ALS, because it is not specific for diagnosis or alters patient management.

3. In the diagnosis or management of metabolic disorders, so do not change managing these.

Policy Guidelines

Intraoperative neurophysiologic monitoring, including somatosensory-evoked potentials and motor evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography of cranial nerves, electroencephalography, and electrocorticography, has broad acceptance, particularly for spine surgery and open abdominal aorta aneurysm repairs.

Constant communication among the surgeon, neurophysiologist, and anesthetist is required for safe and effective intraoperative neurophysiologic monitoring.

In a gamma of other medical settings as stated in Policy regarding somatosensory evoked potential studies, the evidence is sufficient to determine that the technology results in meaningful improvement in the net health outcome.

Benefit Application

BlueCard/National Account Issues

Experimental or investigational procedures, treatments, drugs, or devices are not covered

Background

n/a

Regulatory Status

A number of EEG and EMG monitors have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. FDA product code: GWQ. IONM of MEPs using transcranial magnetic stimulation does not have FDA approval.

Rationale

In cases when neuronal continuity is in question, somatosensory evoked potentials can provide important information regarding the axonal functional continuity. Occasionally dermatomal somatosensory evoked potentials are useful when symptoms are in a distribution not well represented by commonly studied peripheral nerves.

Evoked potentials are the electrical events generated in the central nervous system by peripheral stimulation of a sensory organ. Evoked potentials are used to detect subclinical, abnormal central nervous system function. Detection of a subclinical lesion in a site remote from the region of clinical dysfunction supports a diagnosis of multifocal MS. Evoked potentials also may help define the anatomical site of the lesion in tracts not easily visualized by imaging (eg, optic nerves, dorsal columns).

The three most frequently employed evoked potential tests in clinical use are somatosensory evoked potentials (SSEP), visual evoked responses (VER), and brainstem auditory evoked potentials (BAEP). Patients with clinically definite MS have abnormal VERs in 50 to 90 percent of cases. The VER is particularly useful in patients who lack clear clinical evidence of dysfunction above the level of the foramen magnum, such as those with a chronic progressive myelopathy. Ocular or retinal disorders must be excluded before attributing abnormal VERs to demyelination in the optic pathways.

Population Reference No. 1 Policy Statement

Individuals demonstrating abnormality in the functioning of the sensory nervous system in patients with a questionable clinical presentation

Population Reference No. 1 Policy Statement

[x ] MedicallyNecessary

[ ] Investigational