Benefit Criteria for Evoked Response Tests and Neuromuscular Procedures Update

Date: April 7, 2022 Attention: Neurologists Effective date: March 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons. Providers should direct questions to their Provider Relations Liaison or send an email inquiry to the Provider Relations Department at providerrelations@texaschildrens.org. Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that 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. How this impacts providers: 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 electro-diagnostic 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. Next steps for providers: Providers should share this communication with their staff. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers