Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

Auditory Evoked Potential

Description:

Sensory Evoked Potentials (SEP) are electrical waves that are generated by the response of sensory neurons to stimuli. Changes in the electrical waves are averaged by a computer and then interpreted by a physician. Computer-averaged SEPs (Auditory, Somatosensory, and Visual) can be used to assist the diagnosis of certain neuropathological states or to provide information for treatment management. These tests include:

Auditory evoked potential (also called auditory brainstem response [ABR]) This is an electrophysiologic measure of auditory function that utilizes responses produced by the auditory nerve and the brainstem and helps differentiate sensory from neural hearing loss. The response is the waveform averaged over many auditory clicks. It may be helpful in the diagnosis of cerebellopontine angle tumors and acoustic neuromas, is used as a monitor in posterior fossa surgery, and may help to establish a hearing threshold for infants and difficult-to-test patients;
Visual reinforcement audiometry (VRA) The VRA is part of a battery of tests used in the determination of infant hearing loss. The premise of the test is that the rate of patient response is increased by the use of reinforcement;
Evoked otoacoustic emissions (OAE) Otoacoustic emissions are sounds measured in the external ear canal that are a reflection of the working of the cochlea. A probe and click stimuli are utilized in the performance of this test. OAE is used in the screening as well as the diagnosis of hearing impairment in neonates and young children;
Acoustic reflex test.

This policy addresses only Auditory Evoked Potentials.

Related Policies:

1998095 Intraoperative Neurophysiologic Monitoring

Policy/
Coverage:

Effective May 2015

Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria

Auditory Evoked Potentials (AEP) meet primary coverage criteria for effectiveness and are covered for the following conditions:

Evaluate brain stem function in acquired metabolic disorders, (e.g., hypoxic encephalopathy);
Use as a second line test to disclose the presence of brain stem tumor if MRI or CT does not reveal a tumor or lesion to be present as indicated by clinical examination. Also to disclose the presence of a brain stem tumor if MRI or CT is not available;
Diagnose and monitor the course of demyelinating or degenerative diseases of the brain stem (e.g., MS central pontine myelinolysis and olivopontocerebellar degeneration);
Diagnose the presence of lesions in the auditory system external to the brain stem (e.g., acoustic neuromas);
Assess recovery of brain stem function after removal of space occupying lesions compressing the brain stem;
Supplement the EEG in evaluating the irreversibility of coma or brain death;
Measure the type and extent of hearing impairment;
Determine the degree of neural maturation in neonates, infants, and children less than five years of age.

Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria

The use of auditory evoked potentials for indications other than those listed above, do not meet member benefit certificate primary coverage criteria.

For members with contracts without primary coverage criteria, the use of auditory evoked potential for indications other than those listed above, are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.

**Note: The use of auditory evoked potentials as part of intraoperative monitoring is not addressed in these coverage statements. This use is addressed in Policy # 1998095, Intraoperative Neurophysiologic Monitoring.

Effective Prior to May 2015

Auditory Evoked Potentials (AEP) meet primary coverage criteria for effectiveness and are covered for the following conditions:

Evaluate brain stem function in acquired metabolic disorders, (e.g., hypoxic encephalopathy);
Use as a second line test to disclose the presence of brain stem tumor if MRI or CT does not reveal a tumor or lesion to be present as indicated by clinical examination. Also to disclose the presence of a brain stem tumor if MRI or CT is not available;
Diagnose and monitor the course of demyelinating or degenerative diseases of the brain stem (e.g., MS central pontine myelinolysis and olivopontocerebellar degeneration);
Diagnose the presence of lesions in the auditory system external to the brain stem (e.g., acoustic neuromas);
Assess recovery of brain stem function after removal of space occupying lesions compressing the brain stem;
Supplement the EEG in evaluating the irreversibility of coma or brain death;
Measure the type and extent of hearing impairment;
Determine the degree of neural maturation in neonates, infants, and children less than five years of age.

For Member Benefit Contracts or Plans with Primary Coverage Criteria, Intraoperative Monitoring, is not covered because it fails to meet the Primary Coverage Criteria (“The Criteria”) of the applicable benefit certificate or health plan. (The Criteria require, among other things, that there be scientific evidence of effectiveness, as defined in The Criteria. The Criteria exclude coverage of treatments, such as Intraoperative Monitoring, for which there is lack of scientific evidence).

For Member Benefit Contracts or Plans with explicit exclusion language for experimental or investigational services, Intraoperative Monitoring, is not covered because it is considered experimental or investigational treatment, as defined in the applicable benefit contract or health plan, which excludes coverage of experimental or investigational treatment or services.

Rationale:

In 2000, the American Academy of Pediatrics, as a participant in the Joint Committee on Infant Hearing, published a position statement regarding early hearing detection. This statement recommended that all infants have access to hearing screening using a physiologic measure, with the goal that all infants who do not pass the birth admission screen and any subsequent rescreening begin appropriate audiologic and medical evaluations to confirm the presence of hearing loss before 3 months of age. The position statement noted that otoacoustic emission (OAEs) or auditory brainstem response (ABR) are physiologic techniques that have been successfully used for newborn screening. For example, hospitals may screen with otoacoustic emissions technology or auditory brainstem response technology and retest infants who “refer” with the same or other technology.

2012 Update

A literature search was conducted using the MEDLINE database through April 2012. There was no new literature identified that would prompt a change in the coverage statement.

2014 Update

A literature search conducted through April 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.

Stone and colleges reported their experience utilizing a recently described rapid rate, binaural click and 1000-Hz tone burst modification of the brain stem auditory evoked potentials (BAEP), modified (MBP), in 27 symptomatic patients with non-brain stem compressive space-taking cerebral lesions, hydrocephalus, and pseudotumor cerebri (Stone, 2012). Many presented with clinical signs suggestive of increased intracranial pressure (ICP) and focal neurological deficits. The cerebral lesions, mostly large tumors with edema, had very substantial radiological signs of mass effect. Fourteen patients were also studied following surgical decompression. A number of significant changes in the wave V and Vn latency/intensity and less so amplitude/intensity function was found in the 27 patients, compared to normal volunteers, as well as those studied pre- and postoperatively. Similar MBP changes had been noted in normal volunteers placed in a dependent head position. Possible mechanisms to explain these findings are discussed. The MBP methodology shows promise and further development could make neuro-intensive care unit monitoring practical.

Takai and colleges evaluation of the P50 in resuscitated cardiac arrest patients, noted in general, a prediction of neurologic outcome with respect to the resuscitated cardiac arrest patients has been performed by the auditory brainstem response and somatic evoked potential (Takai, 2011). The auditory brainstem response and somatic evoked potential are known as the predictors that correspond to neurologically poor outcome. None of the methods have been established to access neurologically good outcome. Because the hippocampal CA3 pyramidal cells have been widely used for pathophysiologic analyses concerning the hypoxic-ischemic encephalopathy and also the source of P50 components of the auditory evoked potential has been considered to be the hippocampal CA3 pyramidal cells, the authors assume that it might be possible that neurologic outcome in resuscitated cardiac arrest patients would be predicted by evaluating the P50 components. The purpose was to examine the P50 as a predictor of neurologic outcome in resuscitated cardiac arrest patients at the early stage from the onset. The P50 components of the auditory evoked potential are recorded in a conditioning-testing paradigm, that is, EEG responses to a pair of auditory stimuli with 500-millisecond interclick interval. In this study, subjects are 10 out-of-hospital cardiac arrest patients, 8 men and 2 women with a mean age of 54.8 years, who were admitted to the intensive care unit after the return of spontaneous circulation, with the presence of both the auditory brainstem response wave V and the somatic evoked potential wave N20 between the period from June 2008 to July 2009. It was found that the presence of the P50 at the early stage from the onset (days 5 ± 1.20) indicates good neurologic outcome, while the absence of the P50 implies poor prognosis. As to the auditory sensory gating of the P50, almost no reduction response to the second stimulus was observed. As a consequence, the evaluation of the P50 in resuscitated cardiac arrest patients would have a possibility to predict neurologically good outcome.

2015 Update

A literature search conducted through April 2014 did not reveal any new information that would prompt a change in the coverage statement.

2016 Update

A literature search conducted through April 2016 did not reveal any new information that would prompt a change in the coverage statement

2018 Update

Annual policy review completed with a literature search using the MEDLINE database through April 2018. No new literature was identified that would prompt a change in the coverage statement.

2019 Update

A literature search was conducted through April 2019. There was no new information identified that would prompt a change in the coverage statement.

2020 Update

A literature search was conducted through April 2020. There was no new information identified that would prompt a change in the coverage statement.

2021 Update

Annual policy review completed with a literature search using the MEDLINE database through April 2021. No new literature was identified that would prompt a change in the coverage statement.

2022 Update

Annual policy review completed with a literature search using the MEDLINE database through April 2022. No new literature was identified that would prompt a change in the coverage statement.

2023 Update

Annual policy review completed with a literature search using the MEDLINE database through April 2023. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:

References:

Am Academy of Pediatrics. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000; 106(4):798-817.

Amos NE, Humes LE.(1998) SCAN test-retest reliability for first and third grade children. J Speech Lang Hear Res 1998; 41(4):834-45.

Bamiou DE, Musiek FE, Luxon LM.(2001) Aetiology and clinical presentations of auditory processing disorders – a review. Arch Dis Child 2001; 85(5):361-5.

Domitz DM, Schow RL.(2000) A new CAPD battery – multiple processing assessment: factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2):101-11.

Jerger J, Musiek F.(2000) Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000; 11(9):467-74.

Stone JL1, Fino J, Patel K, Calderon-Arnulphi M, et al.(2012) Modified brain stem auditory evoked potentials in patients with intracranial mass lesions. Clin EEG Neurosci. 2012 Oct;43(4):291-302.

Takai N, Oda S, Sadahiro T, Nakamura M, et. al.(2011) Auditory evoked potential P50 as a predictor of neurologic outcome in resuscitated cardiac arrest patients. J Clin Neurophysiol. 2011 Jun;28(3):302-7.

Task Force on Central Auditory Processing Consensus Development.(1996) American Speech Language Hearing Association. Central auditory processing: Current status of research and implications for clinical practice. Am J Audiol 1996; 5:41-54.

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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