Medical policy: Evoked Potential Studies

Policy number: MP 4.029

Clinical benefit

  • Minimize safety risk or concern.
  • Minimize harmful or ineffective interventions.
  • Assure appropriate level of care.
  • Assure appropriate duration of service for interventions.
  • Assure that recommended medical prerequisites have been met.
  • Assure appropriate site of treatment or service.

Effective date: 4/1/2026

Note: For intraoperative monitoring, refer to MP 2.030 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)

Policy

Somatosensory Evoked Potentials may be considered medically necessary for the following indications:

  • Evaluation of spinal cord lesions secondary to trauma, demyelinating disease, infection, or tumor; or
  • To localize the cause of a central nervous deficit documented on exam, but not explained by MRI or CT; or
  • To evaluate persons with suspected brain death.

Visual Evoked Potentials may be considered medically necessary for the following indications:

  • To aid in the diagnosis and monitoring of multiple sclerosis (MS). Recordings made in the acute phase of MS disclose the presence of active demyelinating plaques. Recordings made in the chronic phase of MS indicate the presence of subclinical plaques; or
  • To localize the basis for visual field defects occurring in the absence of structural lesions, acquired metabolic disease, or infectious disease.

The use of visual evoked potentials is considered investigational for all other indications not listed in the policy, including evaluation for glaucoma. There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with these procedures.

The nonoperative use of somatosensory-evoked potentials are considered investigational for all other indications not listed in the policy. There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with these procedures.

Cross-references

  • MP 2.030 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Evoked potential studies are tests that measure electrical activity or conduction velocities in the central nervous system in response to stimulation of sight, sound, or touch using computerized averaging techniques. These tests are useful in providing information to assist in diagnosing a pathological process and to identify neurological compromise during operative procedures.

Three types of evoked potentials include somatosensory evoked potentials (SSEPs), visual evoked potentials (VEP), and brainstem auditory evoked potentials (BAEPs). These tests can be performed as outpatient diagnostic testing or inpatient for intraoperative monitoring.

Somatosensory evoked potentials (SSEPs) test is useful for diagnosing problems with the spinal cord as well as numbness and weakness of the extremities. During this test, electrodes are attached to the wrist, the back of the knee, or other locations, and a mild electrical stimulus is applied through the electrodes. Scalp electrodes then determine the amount of time it takes for the current to travel along the nerve to the brain.

Visual evoked potentials (VEP) test is used to diagnose problems with delays in the conduction of visual pathways, which may result from the demyelization effects of multiple sclerosis. During this test, electrodes are placed along the scalp, a checkerboard pattern flashes for several minutes on a screen, and electrical responses in the brain are recorded.

Rationale

Visual evoked potentials for glaucoma

One small study supported prospective study was carried out at the New York Eye and Ear Infirmary. Forty-five eyes of 35 patients with glaucomatous optic neuropathy and characteristic glaucomatous visual field (VF) defects were prospectively enrolled. Thirty healthy subjects with normal VF and normal intraocular pressure (IOP < 22 mm Hg) were enrolled.

All patients underwent a complete ophthalmologic examination and had clear media, best corrected visual acuity (BCVA) ≥ 20/30, and pupil diameters > 3 mm and symmetric. Subjects with ocular diseases other than glaucoma, diabetes, or neurological disease were excluded. Glaucoma patients were recruited to be tested at their normally scheduled examination.

The study indicated that the SD‑VEP fixed protocol VEP responses to high‑ and low‑contrast stimuli were able to detect retinal ganglion cells (RGC) function. In addition, the SD‑VEP P100’s low‑contrast latency and high‑contrast amplitude responses sensitivity and specificity remained the same or increased with the progression of RGC damage.

Since this study found strong differences in stimulus study between healthy and glaucoma eyes, and since all glaucoma patients or patients with other diseases of the optic nerve are under the care of a specialist, the fixed protocol was listed as a test which may be beneficial as a singular test in the early detection or diagnosis of such diseases. Further studies are warranted to determine if modifications to the present protocol could better isolate the M and P pathways VEP responses.

Practice guidelines and position statements

The current National Institute for Health and Care Excellence (NICE) Guidance for the diagnosis and management of glaucoma issued November 2017 did not offer support for the use of visual evoked potential studies for the diagnostic evaluation of glaucoma.

The International Glaucoma Association does not make a recommendation on the use of VEP for the evaluation of glaucoma.

Summary

The absence of NICE guidance and other specialty society recommendations at this time is insufficient to support the use of visual evoked potential (VEP) studies for the evaluation of glaucoma. Therefore, the use of VEP in the evaluation of glaucoma is considered investigational.

Definitions

Demyelinate is to destroy or remove the myelin sheath of a nerve fiber as through disease.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Visual evoked potential screenings and testing for glaucoma is considered investigational; therefore, not covered

Procedure codes

0333T

0464T

 

 

 

Covered when medically necessary somatosensory evoked potentials

Procedure codes

95925

95926

95927

95938

 
ICD-10-CM Diagnosis codes
Description

A52.13

Late syphilitic meningitis

A52.14

Late syphilitic encephalitis

A52.15

Late syphilitic neuropathy

A52.17

General paresis

A52.19

Other symptomatic neurosyphilis

A69.21

Meningitis due to Lyme disease

A69.22

Other neurologic disorders in Lyme disease

A69.23

Arthritis due to Lyme disease

A69.29

Other conditions associated with Lyme disease

A83.0

Japanese encephalitis

A83.1

Western equine encephalitis

A83.2

Eastern equine encephalitis

A83.3

St Louis encephalitis

A83.4

Australian encephalitis

A83.5

California encephalitis

A83.6

Rocio virus disease

A83.8

Other mosquito-borne viral encephalitis

A84.0

Far Eastern tick-borne encephalitis [Russian spring-summer encephalitis]

A84.1

Central European tick-borne encephalitis

A84.81

Powassan virus disease

A84.89

Other tick-borne viral encephalitis

A84.9

Tick-borne viral encephalitis, unspecified

A85.2

Arthropod-borne viral encephalitis, unspecified

B00.4

Herpes viral encephalitis

B00.82

Herpes simplex myelitis

B02.24

Postherpetic myelitis

B05.0

Measles complicated by encephalitis

B06.01

Rubella encephalitis

C41.2

Malignant neoplasm of vertebral column

C70.0

Malignant neoplasm of cerebral meninges

C70.1

Malignant neoplasm of spinal meninges

C72.0

Malignant neoplasm of spinal cord

C72.1

Malignant neoplasm of cauda equina

C79.40

Secondary malignant neoplasm of unspecified part of nervous system

D32.1

Benign neoplasm of spinal meninges

D33.3

Benign neoplasm of cranial nerves

D33.4

Benign neoplasm of spinal cord

D42.1

Neoplasm of uncertain behavior of spinal meninges

D42.9

Neoplasm of uncertain behavior of meninges, unspecified

D43.9

Neoplasm of uncertain behavior of cranial nerves

G06.1

Intraspinal abscess and granuloma

G11.0

Congenital nonprogressive ataxia

G11.1

Early-onset cerebellar ataxia

G11.10

Early-onset cerebellar ataxia, unspecified

G11.11

Friedreich ataxia

G11.19

Other early-onset cerebellar ataxia

G11.2

Late-onset cerebellar ataxia

G11.3

Cerebellar ataxia with defective DNA repair

G11.4

Hereditary spastic paraplegia

G11.6

Leukodystrophy with vanishing white matter disease

G11.8

Other hereditary ataxias

G13.0

Paraneoplastic neuropathy and neuropathy

G13.1

Other systemic atrophy primarily affecting central nervous system in neoplastic disease

G23.0

Hallervorden-Spatz disease

G23.1

Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]

G23.2

Striatonigral degeneration

G23.3

Hypomyelination with atrophy of the basal ganglia and cerebellum

G23.8

Other specified degenerative diseases of basal ganglia

G25.3

Myoclonus

G31.80

Leukodystrophy, unspecified

G32.81

Cerebellar ataxia in diseases classified elsewhere

G35

Multiple sclerosis

G35A

Relapsing-remitting multiple sclerosis

G35B

Primary progressive multiple sclerosis

G35B0

Primary progressive multiple sclerosis, unspecified

G35B1

Active primary progressive multiple sclerosis

G35B2

Non-active primary progressive multiple sclerosis

G35C

Secondary progressive multiple sclerosis

G35C0

Secondary progressive multiple sclerosis, unspecified

G35C1

Active secondary progressive multiple sclerosis

G35C2

Non-active secondary progressive multiple sclerosis

G35D

Multiple sclerosis, unspecified

G36.0

Neuromyelitis optica [Devic]

G36.1

Acute and subacute hemorrhagic leukoencephalitis [Hurst]

G36.8

Other specified acute disseminated demyelination

G37.0

Diffuse sclerosis of central nervous system

G37.1

Central demyelination of corpus callosum

G37.2

Central pontine myelinolysis

G37.3

Acute transverse myelitis in demyelinating disease of central nervous system

G37.4

Subacute necrotizing myelitis of central nervous system

G37.5

Concentric sclerosis (Balo) of central nervous system

G37.8

Other specified demyelinating diseases of central nervous system

G37.81

Myelin oligodendrocyte glycoprotein antibody disease

G37.89

Other specified demyelinating diseases of central nervous system

G62.9

Polyneuropathy, unspecified

G90.B

LMNB1-related autosomal dominant leukodystrophy

G92.8

Other toxic encephalopathy

G92.9

Unspecified toxic encephalopathy

G93.1

Anoxic brain damage, not elsewhere classified

G93.42

Megalencephalic leukoencephalopathy with subcortical cysts

G93.43

Leukoencephalopathy with calcifications and cysts

G93.44

Adult-onset leukodystrophy with axonal spheroids

G93.82

Brain death

G95.0

Syringomyelia and syringobulbia

G95.11

Acute infarction of spinal cord (embolic) (nonembolic)

G95.19

Other vascular myelopathies

G95.81

Conus medullaris syndrome

G95.89

Other specified diseases of spinal cord

P91.63

Severe hypoxic ischemic encephalopathy [HIE]

R20.0

Anesthesia of skin

R20.2

Paresthesia of skin

R29.2

Abnormal reflex

R40.20

Unspecified coma

Covered when medically necessary visual evoked potentials

Procedure codes

95930

 

 

 

 
ICD-10-CM Diagnosis codes
Description

G35

Multiple sclerosis

H46.01

Optic papillitis, right eye

H46.02

Optic papillitis, left eye

H46.03

Optic papillitis, bilateral

H46.11

Retrobulbar neuritis, right eye

H46.12

Retrobulbar neuritis, left eye

H46.13

Retrobulbar neuritis, bilateral

H46.2

Nutritional optic neuropathy

H46.3

Toxic optic neuropathy

H46.8

Other optic neuritis

H47.011

Ischemic optic neuropathy, right eye

H47.012

Ischemic optic neuropathy, left eye

H47.013

Ischemic optic neuropathy, bilateral

H47.021

Hemorrhage in optic nerve sheath, right eye

H47.022

Hemorrhage in optic nerve sheath, left eye

H47.023

Hemorrhage in optic nerve sheath, bilateral

H47.031

Optic nerve hypoplasia, right eye

H47.032

Optic nerve hypoplasia, left eye

H47.033

Optic nerve hypoplasia, bilateral

H47.091

Other disorders of optic nerve, not elsewhere classified, right eye

H47.092

Other disorders of optic nerve, not elsewhere classified, left eye

H47.093

Other disorders of optic nerve, not elsewhere classified, bilateral

H47.11

Papilledema associated with increased intracranial pressure

H47.12

Papilledema associated with decreased ocular pressure

H47.13

Papilledema associated with retinal disorder

H47.141

Foster-Kennedy syndrome, right eye

H47.142

Foster-Kennedy syndrome, left eye

H47.143

Foster-Kennedy syndrome, bilateral

H47.211

Primary optic atrophy, right eye

H47.212

Primary optic atrophy, left eye

H47.213

Primary optic atrophy, bilateral

H47.231

Glaucomatous optic atrophy, right eye

H47.232

Glaucomatous optic atrophy, left eye

H47.233

Glaucomatous optic atrophy, bilateral

H47.291

Other optic atrophy, right eye

H47.292

Other optic atrophy, left eye

H47.293

Other optic atrophy, bilateral

H47.311

Coloboma of optic disc, right eye

H47.312

Coloboma of optic disc, left eye

H47.313

Coloboma of optic disc, bilateral

H47.321

Drusen of optic disc, right eye

H47.322

Drusen of optic disc, left eye

H47.323

Drusen of optic disc, bilateral

H47.331

Pseudopapilledema of optic disc, right eye

H47.332

Pseudopapilledema of optic disc, left eye

H47.333

Pseudopapilledema of optic disc, bilateral

H47.391

Other disorders of optic disc, right eye

H47.392

Other disorders of optic disc, left eye

H47.393

Other disorders of optic disc, bilateral

H47.41

Disorders of optic chiasm in (due to) inflammatory disorders

H47.42

Disorders of optic chiasm in (due to) neoplasm

H47.43

Disorders of optic chiasm in (due to) vascular disorders

H47.49

Disorders of optic chiasm in (due to) other disorders

H47.511

Disorders of visual pathways in (due to) inflammatory disorders, right side

H47.512

Disorders of visual pathways in (due to) inflammatory disorders, left side

H47.521

Disorders of visual pathways in (due to) neoplasm, right side

H47.522

Disorders of visual pathways in (due to) neoplasm, left side

H47.531

Disorders of visual pathways in (due to) vascular disorders, right side

H47.532

Disorders of visual pathways in (due to) vascular disorders, left side

H47.611

Cortical blindness, right side of brain

H47.612

Cortical blindness, left side of brain

H47.621

Disorders of visual cortex in (due to) inflammatory disorders, right side of brain

H47.622

Disorders of visual cortex in (due to) inflammatory disorders, left side of brain

H47.631

Disorders of visual cortex in (due to) neoplasm, right side of brain

H47.632

Disorders of visual cortex in (due to) neoplasm, left side of brain

H47.641

Disorders of visual cortex in (due to) vascular disorders, right side of brain

H47.642

Disorders of visual cortex in (due to) vascular disorders, left side of brain

H53.011

Deprivation amblyopia, right eye

H53.012

Deprivation amblyopia, left eye

H53.013

Deprivation amblyopia, bilateral

H53.021

Refractive amblyopia, right eye

H53.022

Refractive amblyopia, left eye

H53.023

Refractive amblyopia, bilateral

H53.031

Strabismic amblyopia, right eye

H53.032

Strabismic amblyopia, left eye

H53.033

Strabismic amblyopia, bilateral

H53.11

Day blindness

H53.121

Transient visual loss, right eye

H53.122

Transient visual loss, left eye

H53.123

Transient visual loss, bilateral

H53.131

Sudden visual loss, right eye

H53.132

Sudden visual loss, left eye

H53.133

Sudden visual loss, bilateral

H53.141

Visual discomfort, right eye

H53.142

Visual discomfort, left eye

H53.143

Visual discomfort, bilateral

H53.15

Visual distortions of shape and size

H53.16

Psychophysical visual disturbances

H53.19

Other subjective visual disturbances

H53.2

Diplopia

H53.31

Abnormal retinal correspondence

H53.32

Fusion with defective stereopsis

H53.33

Simultaneous visual perception without fusion

H53.34

Suppression of binocular vision

H53.411

Scotoma involving central area, right eye

H53.412

Scotoma involving central area, left eye

H53.413

Scotoma involving central area, bilateral

H53.421

Scotoma of blind spot area, right eye

H53.422

Scotoma of blind spot area, left eye

H53.423

Scotoma of blind spot area, bilateral

H53.431

Sector or arcuate defects, right eye

H53.432

Sector or arcuate defects, left eye

H53.433

Sector or arcuate defects, bilateral

H53.451

Other localized visual field defect, right eye

H53.452

Other localized visual field defect, left eye

H53.453

Other localized visual field defect, bilateral

H53.461

Homonymous bilateral field defects, right side

H53.462

Homonymous bilateral field defects, left side

H53.47

Heteronymous bilateral field defects

H53.481

Generalized contraction of visual field, right eye

H53.482

Generalized contraction of visual field, left eye

H53.483

Generalized contraction of visual field, bilateral

H53.51

Achromatopsia

H53.52

Acquired color vision deficiency

H53.53

Deuteranomaly

H53.54

Protanomaly

H53.55

Tritanomaly

H53.59

Other color vision deficiencies

H53.61

Abnormal dark adaptation curve

H53.62

Acquired night blindness

H53.63

Congenital night blindness

H53.69

Other night blindness

H53.71

Glare sensitivity

H53.72

Impaired contrast sensitivity

H53.8

Other visual disturbances

References

  1. American Clinical Neurophysiological Society (ACNS). Guideline 9A: Guidelines on Evoked Potentials. February 2006
  2. American Clinical Neurophysiological Society (ACNS). Guideline 9B: Guidelines on Visual Evoked Potentials. February 2008
  3. American Clinical Neurophysiological Society (ACNS). Guideline 9C: Guidelines on Short-Latency Auditory Evoked Potentials. 2008
  4. American Clinical Neurophysiological Society (ACNS). Guideline 9D: Guidelines on Short-Latency Somatosensory Evoked Potentials. February 2006
  5. Evans, A. Clinical Utility of Evoked Potentials. eMedicine updated 01/25/2019 eMedicine
  6. NICE Guideline Glaucoma: Diagnosis and management November 2017; last updated January 2022
  7. Pillai C, Pitch R, et al. Sensitivity and Specificity of Short Duration Transient Visual Evoked Potential (SD‑VEP) in Discrimination Normal From Glaucomatous Eyes. Invest Ophthalmol. Vis. Sci. April 23, 2013 vol. 54 no. 4 2847‑2852
  8. Olek M. Evaluation and diagnosis of multiple sclerosis in adults. In: UpToDate Online Journal (serial online). Waltham, MA: UpToDate; updated April 30, 2024
  9. Weinhouse G., Young, B. Hypoxic‑ischemic brain injury in adults. Evaluation and prognosis. In: UpToDate Online Journal (serial online). Waltham, MA: UpToDate; updated May 22, 2024
  10. American Association of Neuromuscular & Electrodiagnostic Medicine. Somatosensory Evoked Potentials: Clinical Uses.

Policy history

MP 4.029

07/17/2020 Consensus review. No changes to the policy statements. References reviewed.

06/17/2020 Consensus review. No change to policy statements. References updated. Rationale updated to include the updated NICE guidelines.

05/19/2021 Consensus review. No change to policy statements. References updated. Coding updated 92585 and 92586 were deleted and replaced with 92650‑92653. Dx coding updated.

09/07/2021 Administrative update. New codes G44.8 and G92.9 added. Effective 10/01/2021.

03/18/2022 Minor review. Deleted MN criteria and codes on brainstem auditory testing. Updated FEP, background, ICD‑10 table, and references.

08/03/2023 Consensus review. No change to policy language or intent.

01/19/2024 Administrative update. Clinical benefit added.

01/08/2025 Consensus review. No change to policy statement. References updated.

09/03/2025 Administrative update. New ICD‑10 codes added as part of new code for 10/01/2025.

09/08/2025 Administrative update. Removed benefit variations section and updated disclaimer.

10/31/2025 Consensus review. No change to policy statement. References updated.