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Date Printed: December 18, 2017: 11:37 AM

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This medical policy (medical coverage guideline) is Copyright 2017, 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 2017 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.

01-92502-12

Original Effective Date: 12/15/03

Reviewed: 05/25/17

Revised: 06/15/17

Subject: Computerized Dynamic Posturography

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:

Computerized dynamic posturography (CDP) attempts to provide quantitative information regarding the functional ability to maintain balance. The patient, wearing a harness to prevent falls, stands on an enclosed platform surrounded by a visual field. By altering the angle of the platform or shifting the visual field, the test assesses movement coordination and the sensory organization of visual, somatosensory, and vestibular information relevant to postural control. Results of posturography have been used to determine what type of information (i.e., visual, vestibular, proprioceptive) can and cannot be used to maintain balance. CDP cannot be used to localize the site of a lesion. The Food and Drug Administration (FDA) approved the EquiTest™ for computerized dynamic posturography.

Other dynamic posturography device makers include Micromedical Technology, Metitur, Vestibular Technologies and Medicapteurs.

POSITION STATEMENT:

Dynamic posturography is considered experimental or investigational, as there is insufficient clinical evidence in the peer-reviewed medical literature to support the use of dynamic posturography for assessing balance problems. There is a lack of scientific evidence in the peer-reviewed literature to demonstrate improved treatment decision-making. There is insufficient evidence to determine whether dynamic posturography detects vestibular dysfunction or whether dynamic posturography distinguishes between peripheral and central vestibular dysfunction. The available studies fail to evaluate sensitivity and specificity relative to a reliable and valid reference standard.

BILLING/CODING INFORMATION:

CPT Coding:

92548

Computerized dynamic posturography (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Computerized Dynamic Posturography, (L33987) located at fcso.com.

DEFINITIONS:

No guideline related definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report dynamic posturography:

Note: 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.

Automated posturography
Computerized dynamic posturography (CDP)
Computerized posturography
Computerized platform posturography
EquiTest
Moving platform posturography
Test of Balance (TOB)

REFERENCES:

  1. Alahmari KA, Marchetti GF, Sparto PJ, et al. Estimating postural control with the balance rehabilitation unit: measurement consistency, accuracy, validity, and comparison with dynamic posturography. Archives of Physical Medicine Rehabilitation 2014; 95(1):65-73.
  2. American Academy of Neurology, Assessment: Vestibular Testing Techniques in Adults and Children, 2000.
  3. American Academy of Otolaryngology-Head and Neck Surgery. Position Statement: Posturography, 2014.
  4. Badke MB, Miedaner JA, Shea TA et al. Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap. Annals of Otology, Rhinology, and Laryngology. 2005; 114(1 Pt1): 48-54.
  5. Blue Cross Blue Shield Association Medical Policy. Dynamic Posturography 2.01.02/17.
  6. Blue Cross Blue Shield Association TEC Assessment-Dynamic Posturography in the Assessment of Vestibular Dysfunction Vol 11, No. 11, 09/96.
  7. Emam AA, Gad AM, Ahmed MM et al. Ouantitative assessment of posture stability using computerized dynamic posturography in type 2 diabetic patients with neuropathy and its relation to glycaemic control. Singapore Medical Journal 2009; 50(6):614-618.
  8. EquiTest® NeruoCom Systems computerized Dynamic Posturography (CDP), 2005.
  9. Ferrazzoli D, Fasano A, Maestri R, et al. Balance dysfunction in Parkinson's disease: the role of posturography in developing a rehabilitation program. Parkinsons Disease 2015:520128.
  10. Fritz NE, Newsome SD, Eloyan A, et al. Longitudinal relationships among posturography and gait measures in multiple sclerosis. Neurology 2015;84(20):2048-2056.
  11. Gouveris H, Stripf T, Victor A et al. Dynamic posturography findings predict balance status in vestibular schwannoma patients. Otology & Neurotology. 2007; 28(3): 372-375.
  12. Miedaner JA, Grove CR, Shea TA, et al. Effects of Vestibular and Balance Rehabilitation on Sensory Organization and Dizziness Handicap. Annals of Otology, Rhinology & Laryngology 2005; 114: 48-54.
  13. Mirka A, Black FO. Clinical application of dynamic posturography for evaluating sensory integration and vestibular dysfunction. Neurology Clinical. 1990; 8(2): 351-359.
  14. Nicolas P, Eduardo M, Rafael Garcia-Tapia. Dizziness: Relating the Severity of Vertigo to the Degree of Handicap by Measuring Vestibular Impairment. Otolaryngology-Head and Neck Surgery 2003; 128(3): 372-381.
  15. Nocera J, Horvat M, Ray CT. Effects of home-based exercise on postural control and sensory organization in individuals with Parkinson disease. Parkinsonism & Related Disorders 2009; 15(10): 742-745.
  16. Perez N, Martin E, Garcia-Tapia R. Dizziness: relating the severity of vertigo to the degree of handicap by measuring vestibular impairment. Otolaryngology Head and Neck Surgery. 2003; 128(3): 372-381.
  17. Stewart MG, Chen AY, Wyatt JR et al. Cost-effectiveness of the diagnostic evaluation of vertigo. Laryngoscope. 1999; 109(4): 600-605.
  18. Teggi R, Caldirola D, Fabiano B et al. Rehabilitation after acute vestibular disorders. The Journal of Laryngology and Otology 2009; 123(4): 397-402.
  19. Whitney SL, Marchetti GF, Schade AI. The relationship between falls history and computerized dynamic posturography in persons with balance and vestibular disorders. Archives of Physical Medicine and Rehabilitation. 2006; 87(3):402-407.
  20. Whitney SL, Roche JL, Marchetti GF et al. A comparison of accelerometry and center of pressure measures during computerized dynamic posturography: a measure of balance. Gait Posture 2011; 33(4):594-99.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/25/17.

GUIDELINE UPDATE INFORMATION:

12/15/03

New Medical Coverage Guideline.

12/15/04

Reviewed; no change in investigational status.

02/15/06

Revised description section. Added program exception (covered indications and ICD-9 codes that support medical necessity-*note-expanded codes to include the 4th and 5th digit) for Medicare Advantage products, and updated references.

02/15/07

Scheduled review. No change in investigational status. Updated Medicare Advantage products program exception; deleted 850.20 – 850.29 code range, and updated references.

06/15/07

Reformatted guideline; references updated.

02/15/08

Scheduled review. No change in position statement (investigational). Added computerized to MCG title. Revised descriptor. Updated Medicare Advantage products program exception, and updated references.

02/15/09

Scheduled review. No change in position statement (experimental or investigational), and updated references.

02/15/10

Scheduled review. No change in position statement (experimental or investigational). Updated references. Deleted Medicare Advantage products program exceptions.

04/15/11

Added Medicare Advantage products program exceptions. Updated references.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

06/15/17

Review; no change in position statement. Updated references.

Date Printed: December 18, 2017: 11:37 AM