mp-268 - mp-268 - Medical Policies
Policy Number: MP-268
Latest Review Date: February 2020
Policy Grade: C
Dynamic posturography to assess vestibular dysfunction is considered not medically necessary and investigational.
DESCRIPTION OF PROCEDURE OR SERVICE:
Dynamic posturography tests a patient’s balance control in situations intended to isolate factors that affect balance in everyday experiences. It provides quantitative information on the degree of imbalance present in an individual but is not intended to diagnosis specific types of balance disorders.
Complaints of imbalance are common in older adults and contribute to the risk of falling in this population. Falls are an important cause of death and disability in this population in the United States. Maintenance of balance is a complex physiologic process, requiring interaction of the vestibular, visual, and proprioceptive/somatosensory system, and central reflex mechanisms. Balance is also influenced by the general health of the patient (i.e., muscle tone, strength, range of motion). Therefore, identifying and treating the underlying balance disorder can be difficult. Commonly used balance function tests (e.g., electronystagmography, rotational chair tests) attempt to measure the extent and site of a vestibular lesion but do not assess the functional ability to maintain balance.
Role in Diagnosis
Dynamic posturography aims to provide more quantitative information regarding the functional ability for maintaining 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. The patient undergoes six different testing situations designed to evaluate the vestibular, visual, and proprioceptive/somatosensory components of balance. In general terms, the test measures an individual’s balance (as measured by a force platform to calculate the movement of the patient’s center of mass) while visual and somatosensory cues are altered. These tests vary by whether the eyes are open or closed, whether the platform is fixed or sway-referenced, and whether the visual surround is fixed or sway-referenced. Sway referencing involves making instantaneous computer-aided alteration in the platform or visual surround to coincide with changes in body position produced by sway. The purpose of sway referencing is to cancel out accurate feedback from somatosensory or visual systems that are normally involved in maintaining balance. In the first three components of the test, the support surface is stable, and visual cues are either present, absent, or sway-referenced. In tests 4 to 6, the support surface is sway-referenced to the individual, and visual cues are either present, absent, or sway-referenced. In tests 5 and 6, the only accurate sensory cues that are available for balance are vestibular cues. Results of computerized dynamic posturography have been used to determine what type of information (i.e., visual, vestibular, proprioceptive) can and cannot be used to maintain balance. Dynamic posturography cannot be used to localize the site of a lesion.
Posturography tests a patient’s balance control in situations intended to isolate factors that affect balance in everyday experiences. Balance can be rapidly assessed qualitatively by asking the patient to maintain a steady stance on a flat or compressible surface (i.e., foam pads) with the eyes open or closed. By closing the eyes, the visual input into balance is eliminated. Use of foam pads eliminates the sensory and proprioceptive cues. Therefore, only vestibular input is available when standing on a foam pad with eyes closed.
The policy was updated regularly using the MEDLINE database through December 09, 2019.
SUMMARY OF EVIDENCE:
For individuals with suspected balance disorders who receive dynamic posturography, the evidence includes cross-sectional comparisons of results in patients with balance disorders and healthy controls and retrospective case series reporting outcomes for patients assessed with dynamic posturography as part of clinical care. Relevant outcomes are test accuracy and validity, symptoms, and morbid events. There are no generally accepted reference standards for dynamic posturography, which makes it difficult to determine how testing results can be applied in clinical care. There are no studies demonstrating the clinical utility of the test that would lead to changes in management that improve outcomes (e.g., symptoms, function). The evidence is insufficient to determine the effects of the technology on health outcomes.
PRACTICE GUIDELINES AND POSITION STATEMENTS:
The American Academy of Otolaryngology-Head and Neck Surgery
The American Academy of Otolaryngology-Head and Neck Surgery foundation has issued 2 guidelines that mention dynamic posturography:
- Revised in September 2014, a position statement on the evaluation or therapy of individuals with suspected balance or dizziness disorders, listed dynamic posturography as 1 of 4 medically indicated tests or evaluation tools.
- In 2017, updated guidelines on the management of benign paroxysmal positional vertigo were published; posturography is not mentioned.
U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS:
Dynamic posturography, vestibular dysfunction, EquiTest,
APPROVED BY GOVERNING BODIES:
In 1985, the NeuroCom EquiTest® (NeuroCom International, Portland, OR; now Clackamas, OR), a dynamic posturography device, was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. Other dynamic posturography device makers include Vestibular Technologies (Cheyenne, WY) and Medicapteurs (Balma, France). Companies that previously manufactured dynamic posturography devices include Metitur (Jyvaskyla, Finland) and Micromedical Technology (Chatham, IL).
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
92548 Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (i.e. eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report
92549 ;with motor control test (MCT) and adaptation test (ADT)
- 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. Arch Phys Med Rehabil. Jan 2014; 95(1):65-73.
- Alluma JH, et al. An overview of the clinical use of dynamic posturography in the differential diagnosis of balance disorders. Journal of Vestibular Research, January 1999; 9(4): 223-252.
- American Academy of Otolaryngology—Head and Neck Surgery. Posturography. www.entnet.org/Practice/policyPosturography.cfm.
- Badke MB, Miedaner JA, Shea TA, et al. Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap. Ann Otol Rhinol Laryngol, January 2005; 114(1 Pt 1): 48-54.
- Badke MB, Shea TA, Miedaner JA and Grove CR. Outcomes after rehabilitation for adults with balance dysfunction. Arch Phys Med Rehabil 2004; 85(2): 227-233.
- Baloh RW, et al. Balance disorders in older persons: Quantification with posturography. Otolaryngology—Head and Neck Surgery, July 1998; 119(1): 89-92.
- Baloh RW, et al. Comparison of static and dynamic posturography in young and older normal people. Journal of American Geriatric Society, April 1994; 42(4): 405-412.
- Baloh RW, et al. Posturography and balance problems in older people. Journal of the American Geriatric Society, June 1995; 43(6): 638-644.
- Baloh, RW. Static and dynamic posturography in patients with vestibular and cerebellar lesions. Archives of Neurology, May 1998; 55(5): 649-654.
- Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice guideline: Benign paroxysmal positional vertigo. Otolaryngology—Head and Neck Surgery (2008); 139:S47-S81.
- Biggan JR, Melton F, Horvat MA et al. Increased load computerized dynamic posturography in pre-frail and non-frail community dwelling older adults. J aging phys Act 2013.
- Blue Cross Blue Shield Association. Technology Evaluation Criteria (TEC) Assessment 1996, Tab 11.
- Bogaerts A, Verschueren S, Delecluse C, et al. Effects of whole body vibration training on postural control in older individuals: A 1 year randomized controlled trial. Gait & Posture, July 2007; 26(2): 309-316.
- Brown KE, Whitney SL, Marchetti, GF, et al. Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil, January 20006; 87(1): 76-81.
- Buatois S, Gueguen R, Gauchard GC, et al. Posturography and risk of recurrent falls in healthy non-institutionalized persons aged over 65. Gerontology, January 2006; 52(6): 345-352.
- Carter ND, et al. Community-based exercise program reduces risk factors for falls in 65-to75-year old women with osteoporosis: Randomized controlled trial. Canadian Medical Association Journal, October 2002, Vol. 167, No. 9.
- Clendaniel RA. Outcome measures for assessment of treatment of the dizzy and balance disorder patient. Otolaryngol Clin North Am. 2000; 33(3):519-533.
- Clendaniel RA. Practical issues in the management of the dizzy and balance disorder patient. Otolaryngologic Clinics of North America, June 2000, Vol. 33, No. 3.
- Cohen HS, et al. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngology—Head and Neck Surgery, April 2004; 130(4): 418-425.
- Cohen HS, et al. Factors affecting recovery after acoustic neuroma resection. Acta Oto-Laryngological, December 2002; 122(8): 841-850.
- Ebersbach G, Gunkel M. Posturography reflects clinical imbalance in Parkinson’s disease. Mov Disord 2011; 26(2):241-6.
- Evans MK, et al. Posturography does not test vestibulospinal function. Otolaryngology—Head and Neck Surgery, February 1999; 120(2): 164-173.
- Ferrazzoli D, Fasano A, Maestri R, et al. Balance dysfunction in Parkinson's disease: the role of posturography in developing a rehabilitation program. Parkinsons Dis. 2015; 2015:520128.
- Fritz NE, Newsome SD, Eloyan A, et al. Longitudinal relationships among posturography and gait measures in multiple sclerosis. Neurology. May 19 2015; 84(20):2048-2056.
- Furman JM. Role of posturography in the management of vestibular patients. Otolaryngology—Head and Neck Surgery, January 1995; 112(1): 8-15.
- Ganesan M, Pasha SA, Pal PK et al. Direction specific preserved limits of stability in early progressive supranuclear palsy: a dynamic posturographic study. Gait Posture 2012; 35(4):625-9.
- Girardi M, et al. Predicting fall risks in an elderly population: Computer dynamic posturography versus electronystagmography test results. Laryngoscope, September 2001; 111(9): 1528-1532.
- Hirsch MA, et al. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson’s disease. Archives of Physical Medicine and Rehabilitation, August 2003; 84(8): 1109-1117.
- Honaker JA, Converse CM, Shepard NT. Modified head shake computerized dynamic posturography. American Journal of Audiology, 2009 Dec; 18(2):108-13.
- Izquierdo-Renau M, Perez-Soriano P, Ribas-Garcia V, et al. Intra and intersession repeatability and reliability of the S-Plate(R) pressure platform. Gait Posture. Dec 02 2016;.52:224-226.
- Lee JM, Koh SB, Chae SW et al. Postural instability and cognitive dysfunction in early Parkinson's disease. Can J Neurol Sci 2012; 39(4):473-82.
- Lim KB, Lee HJ. Computerized posturographic measurement in elderly women with unilateral knee osteoarthritis. Ann Rehabil Med 2012; 36(5):618-26.
- Ludin F, Ledin T, Wikkelso C et al. Postrual function in idiopathic normal pressure hydrocephalus before and after shunt surgery: a controlled study using computerized dynamic posturography (EquiTest). Clin Neurol Neurosurg 2013; 115(9):1626-31.
- Marchetti GF, et al. Older adults and balance dysfunction. Neurologic Clinics, August 2005, Vol. 23, No. 3.
- Nocera J, Horvat M and Ray CT. Effects of home-based exercise on postural control and sensory organization in individuals with Parkinson disease. Parkinsonism Relat Disord, December 2009; 15(10): 742-745.
- O’Neill DE, et al. Posturography changes do not predict functional performance changes. American Journal of Otology, November 1998; 19(6): 797-803.
- Pang MY, Lam FM, Wong GH, et al. Balance performance in head-shake computerized dynamic posturography: aging effects and test-retest reliability. Phys Ther. 2011; 91(2):246-253.
- Pierchala K, Lachowska M, Morawski K et al. Sensory Organization Test outcomes in young, older and elderly healthy individuals - preliminary results. Otolaryngol Pol 2012; 66(4):274-79.
- Qutubuddin AA, Cifu DX, et al. A comparison of computerized dynamic posturography therapy to standard balance physical therapy in individuals with Parkinson’s disease: A pilot study. NeuroRehabilitation 2007; 22(4): 261-265.
- Reid VA, et al. Using posturography to detect unsteadiness in 13 patients with peripheral neuropathy: A pilot study. Neurology and Clinical Neurophysiology, January 2002; 2002(4): 2-8.
- Rubin AM Et Al. The assessment and management of the dizzy patient. Otolaryngologic Clinics of North America, April 2002, Vol. 35, No. 2.
- Ruckenstein MJ, et al. Practical issues in the management of the dizzy and balance disorder patient. Otolaryngologic Clinics of North America, June 2000, Vol. 33, No. 3.
- Sinaki M, Lynn SG. Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study. American Journal of Physical and Medical Rehabilitation 2002 Apr; 81(4):241-6.
- Teggi R, Caldirola D, Fabiano B, et al. Rehabilitation after acute vestibular disorders. J Laryngol Otol, April 2009; 123(4): 397-402.
- Visser JE, Oude Nijhuis LB, Janssen L, et al. Dynamic posturography in Parkinson’s disease: diagnostic utility of the “first trial effect”. Neuroscience. 2010 Jun 30; 168(2):387-94 Epub 2010 Apr 7.
- Whitney SL, Marchetti GF and Schade AI. The relationship between falls history and computerized dynamic posturography in persons with balance and vestibular disorders. Arch Phys Med Rehabil, March 2006; 87(3): 402-407.
- 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):594-599.
Medical Policy Group, March 2006 (3)
Medical Policy Administration Committee, April 2006
Available for comment May 5-June 19, 2006
Medical Policy Group, March 2007 (1)
Key Points updated, references added: March 2008 (1)
Medical Policy Group, March 2009 (1)
Medical Policy Group, March 2010 (1): Key points updated, no policy change, references added
Medical Policy Group, November 2010 (1): Description updated, Approved Governing Bodies updated, References updated
Medical Policy Group, November 2011 (1): Update to Key Points and References; no changes in policy statement
Medical Policy Group, November 2012 (1): Update to Key Points and References; no changes in Policy statement.
Medical Policy Panel, November 2013
Medical Policy Group, January 2014 (2): No change to policy statement. Update to Key Points and References based on latest literature search.
Medical Policy Panel, November 2014
Medical Policy Group, November 2014 (4): No change to policy statement. Update to Key Points and References
Medical Policy Panel, February 2017
Medical Policy Group, February 2017 (6): Updates to Description, Key Points, Governing Bodies, Practice Guidelines and References; no change in policy statement.
Medical Policy Panel, February 2018
Medical Policy Group, February 2018 (6): Updates to Description and Key Points.
Medical Policy Panel, February 2019
Medical Policy Group, February 2019 (6): Updates to Key Points and added Key Word “Equitest”.
Medical Policy Group, December 2019 (6): 2020 Annual Coding Update, Revised code 92548, added code 92549.
Medical Policy Panel, February 2020
Medical Policy Group, February 2020 (6): Updates to Key Points and Practice Guidelines.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.