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This medical policy (medical coverage guideline) is Copyright 2016, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92502-14

Original Effective Date: 06/15/05

Reviewed: 05/26/11

Revised: 11/01/15

Subject: Vestibular Rehabilitation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

There are two general approaches to vestibular rehabilitation implementation – particle repositioning maneuvers and graded exercises programs. Particle repositioning maneuvers strive to relocate displaced otoconia residing in the semicircular canal into the utricle, where they become harmless. This relocation is performed by rotating the head and the body in a series of maneuvers. Graded exercises involve repetitive movements or prolonged exposure, with the goal being to loosen and disperse the debris from the cupula.

Vestibular rehabilitation exercises are different from canalith repositioning maneuvers. Vestibular rehabilitation describes a series of exercises designed to correct maladaptive postural control strategies, or to overcome poor central nervous system compensation after an acute injury to the vestibular system. Canalith repositioning maneuvers are designed to address the underlying cause of benign positional paroxysmal vertigo (BPPV). The goals of vestibular rehabilitation are to improve balance, minimize falls, and decrease dizziness by restoring normal vestibular function and promoting mechanisms of central adaptation and compensation.

The accurate diagnosis and assessment of the individual is critical for a successful individualized program. The diagnosis and assessment include quantifying the degree of damage to peripheral vestibular structures and central vestibular pathways and evaluating the level of physiologic and neurologic compensation that may have already occurred. Functional abilities such as gait, ambulation with head movement, balance with altered sensory cues, and balance under static (i.e., sitting, standing) and dynamic conditions are assessed. Sensory evaluation should include visual and proprioceptive abilities since multi-sensory deficits can impede functional progress.

Patient assessment should also include a complete medical history and a detailed history of the balance symptoms experienced by the patient, including a description of the type of symptoms (e.g., vertigo, imbalance, disequilibrium, pre-syncopal sensations, gait ataxia), frequency and duration of symptoms, specific activities or positions that provoke symptoms, presence of visual disturbances, and the patient's perception of the impact of the symptoms on daily activities.

POSITION STATEMENT:

Vestibular rehabilitation meets the definition of medical necessity for the treatment of chronic vertigo when ALL of the following criteria are met:

  1. The individual has a diagnosis of vertigo, benign paroxysmal positioning vertigo or has had ablative vestibular surgery.
  2. Symptoms of vertigo and imbalance have existed for duration of 8 weeks or more.
  3. The individual has persistent symptoms despite optimal medical management such as vestibular suppressant medication prescribed to reduce symptoms.

BILLING/CODING INFORMATION:

The following codes may be used to describe vestibular rehabilitation:

HCPCS Coding:

S9476

Vestibular rehabilitation program, non-physician provider, per diem

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

H81.01 – H81.93

Disorders of vestibular function

H82.1 – H82.9

Vertiginous syndromes in diseases classified elsewhere

H83.01 – H83.09

Labyrinthitis

H83.11 – H83.19

Labyrinthine fistula

H83.2X1 – H83.2X9

Labyrinthine dysfunction

H83.8X1 – H83.8X9

Other specified diseases of inner ear

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, medication history and operative report (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

History of medication use

10160-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Surgical report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Vestibular rehabilitation is limited to 12 visits initially. An additional 12 visits may be medically necessary and are subject to medical review for evidence of clinically significant improvement. If improvement is not documented, the additional 12 visits are not considered medically necessary.

NOTE: Vestibular rehabilitation services are considered part of the contract benefit for rehabilitative services.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Cupula: the bony apex of the cochlea.

Otoconia: small crystals of calcium carbonate in the saccule and utricle of the ear that under the influence of acceleration in a straight line cause stimulation of the hair cells by their movement relative to the gelatinous supporting substrate containing the embedded cilia of the hair cells – called also statoconia.

Proprioceptive: activated by, relating to, or being stimuli arising within the organism.

Saccule: the smaller chamber of the membranous labyrinth of the ear.

Utricle: the part of the membranous labyrinth of the ear into which the semicircular canals open.

Vertigo: the sensation of moving around in space (subjective vertigo) or of having objects move about the person (objective vertigo).

Vestibular: of or relating to the vestibule of the inner ear, the vestibular apparatus, the vestibular nerve, or the labyrinthine sense.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Speech-Language-Hearing Association. Role of Audiologist in Vestibular and Balance Rehabilitation: Position Statement (1999). Accessed 04/15/11.
  2. Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003 May; 128(5): 719-25.
  3. Baylor College of Medicine website: Vestibular Rehabilitation. Last modified 02/14/11. (Accessed 04/15/11).
  4. Bhattacharyy, N, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery (2008) 139, S47-S81.
  5. Blue Cross Blue Shield Association. Medical Policy Reference Manual. Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Vertigo (BPPV) 2.01.37, 12/15/00 (archived 07/08/10).
  6. Cohen HS, Kimball KT. Changes in repetitive head movement task after vestibular rehabilitation. Clin Rehabil. 2004 Mar; 18(2): 125-31.
  7. Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2004 Apr; 130(4): 418-25.
  8. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2003 Jan; 128 (1): 60-70.
  9. Duke University Health Services website: Vestibular Rehabilitation, (accessed 04/15/11).
  10. ECRI Windows on Technology. “Vestibular Rehabilitation and Particle Repositioning for Benign Positional Vertigo” (01/03).
  11. Hayes Medical Technology Directory, Vestibular Rehabilitation for the Treatment of Vestibular and Balance Disorders, VEST0501.04, (10/99; updated 09/07/05).
  12. Krebs DE, Gill-Body KM, Parker SW, et al. Vestibular rehabilitation: useful but not universally so. Otolaryngol Head Neck Surg. 2003 Feb; 128(2): 240-50.
  13. Pavlou M, Lingeswaran A, Davies, RA, Gresty MA, Bronstein AM. Simulator based rehabilitation in refractory dizziness. J Neurol. 2005 Aug; 251(8): 983-95.
  14. Rine, RM, Braswell J, Fosher D, Joyce K, Kalar K, Shaffer M. Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. Int J Pediatr Otorhinolaryngol. 2004 Sept; 68(9): 1141-8.
  15. St. Anthony’s Level II HCPCS coding (current edition).
  16. Yardley L., Donovan-Hall M, Smith HE, Walsh BM, Mullee M, Bronstein AM. Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness. ANN Intern Med. 2004 Oct 19; 141(8): 641-3.
  17. Zapanta PE, Meyers AD, et al. Vestibular Rehabilitation. E-medicine-Medscape. Updated 11/09/09. Accessed 04/18/11.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/26/11.

GUIDELINE UPDATE INFORMATION:

06/15/05

New Medical Coverage Guideline.

06/15/07

Scheduled review; reformatted guideline; updated references.

06/15/09

Scheduled review of guideline. Update position statement and ICD 9 coding section. Remove reference to canalith repositioning guideline.

10/15/10

Revision; related ICD-10 codes added.

06/15/11

Scheduled review; Position Statement unchanged; references updated; formatting changes.

09/15/11

Revision; formatting changes.

02/15/14

Revision; Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: May 30, 2016: 08:25 AM