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Benefit Criteria for Evoked Response Tests and Neuromuscular Procedures to be Added Effective March 1, 2022

Last updated on 1/14/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2022, benefit criteria will be added for vestibular evoked myogenic potentials (VEMP) procedure codes 92517, 92518, and 92519.

Conditions

Some conditions under which VEMP testing (procedure codes 92517, 92518, and 92519) may be appropriate include:

  • Evaluation of chronic symptoms of pressure, tinnitus, disorientation, or chronic vertigo after all other recommended vestibular tests has been completed and a definitive diagnosis is lacking.
  • Evaluation is required after a positive computed tomography (CT) scan for superior semicircular canal dehiscence syndrome (SCDS).

Documentation must include the following:

  • The other differential diagnoses under consideration
  • The additional diagnoses considered
  • The clinical signs, symptoms, or electrodiagnostic findings that necessitated the inclusion

Reimbursement

VEMP testing procedure codes 92517, 92518, and 92519 must be medically indicated and may be reimbursed when submitted with one of the following diagnosis codes:

Diagnosis Codes

H81311

H81312

H81313

H81319

H81391

H81392

H81393

H81399

H814

H8190

H8191

H8192

H8193

H821

H822

H823

H829

H8301

H8302

H8303

H8309

H8311

H8312

H8313

H8319

H832X1

H832X2

H832X3

H832X9

H833X1

H833X2

H833X3

H833X9

H838X1

H838X2

H838X3

H838X9

H8390

H8391

H8392

H8393

H9311

H9312

H9313

H9319

R110

R111

R112

R42

         

VEMP testing is not medically necessary for any other indications.

Documentation Requirements

All the following criteria are documentation requirements for VEMP testing:

  • For each VEMP test performed, the referral reason must include a clear diagnostic impression documented in the client’s medical record.
  • Medical necessity for the VEMP test must be clearly documented in the client’s medical record and reflect the actual results of specific tests (which could include latency and amplitude).
  • Medical necessity of client reevaluation after the initial consultation and testing must be clearly documented. Supporting documentation must include the following:
  • New symptoms unrelated to previously evaluated symptoms, which may result in a new diagnosis
  • Rapidly changing client condition documentation, supported by the following:
  • Diagnosis
  • Current clinical signs and symptoms
  • Prior clinical condition
  • Expected clinical disease course
  • Clinical benefit of additional studies

The client’s medical records are subject to retrospective review.

For more information, call the TMHP Contact Center at 800-925-9126.