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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

-- [ Page 66 ] --

Adoption Date: 09/16/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

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Computerized Dynamic Posturography - Commercial Medical Management Guideline Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.

Coverage Rationale Computerized dynamic posturography (CDP) testing, also called balance board testing or equilibrium platform testing (EPT), is unproven for evaluating balance disorders. The overall quality of the evidence on the efficacy of computerized dynamic posturography (CDP) for evaluation of vestibular disorders is weak. There is a lack of welldesigned, prospective, randomized controlled trials using blind assessment to demonstrate the diagnostic utility of CDP compared with standard tests. There are no reliable data demonstrating any consistent, beneficial effect of CDP testing on patient outcomes.

See the medical policy Transtympanic Micropressure for the Treatment of Meniere's Disease for information on a portable, low-pressure pulse generator device as an alternative to surgery for people with Meniere's disease.

Regulatory Requirements U.S. Food and Drug Administration (FDA): The EquiTest®most frequently discussed CDP system in the medical

literature, received FDA approval on August 5, 1985. See the following Web site for more information:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=57214. Accessed April 2009.

Devices for testing vestibular dysfunction are captured in the FDA 510(k) database under Product Code LXV (Vestibular Analysis Apparatus) and/or Product Code KHX (Force-Measuring Platforms). Devices with Product Code LXV are unclassified and devices falling under the Product Code KHX are 510(k)-exempt. See the following Web site for more information: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm. Accessed April 2009.

Another device mentioned in the literature is the Balance Quest™ (also known as System 2000; Vorteq) (Micromedical

Technologies Inc.), which is listed as an unclassified device. See the following Web sites for more information:

http://www.micromedical.com/balancequest.html. Accessed April 2009.

Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRL/rl.cfm. (search: Micromedical as Establishment Name). Accessed April 2009.

Research Evidence Background A balance or vestibular disorder refers to a problem with the structure in the inner ear that is responsible for balance.

Diagnosis is complicated due to the number of possible underlying causes, and since dizziness is also associated with nonvestibular problems such as ear infection, abnormal blood flow in the brain, and anxiety. Initial testing includes a thorough patient history and physical examination. Standard diagnostic tests include electronystagmography and rotational chair tests, which evaluate eye movements in response to a number of different stimuli including the position and rotation of the head. Computerized dynamic posturography (CDP) is being investigated as an alternative to standard diagnostic tests. CDP has been used to measure a patient's ability to maintain balance under varying conditions when the usual cues that one relies upon to remain upright, vision, proprioception, and vestibular function, are manipulated. The goal of testing is to isolate vestibular symptoms to a specific cause that can often be treated.

Research Evidence In a systematic review, Piirtola and Era evaluated prospective studies where force platform measurements were used as predictors of falls among elderly populations. Nine original prospective studies were included in the final analyses. In five studies fall-related outcomes were associated with some force platform measures and in the remaining four studies associations were not found. Measures related to dynamic posturography (moving platforms) were not predictive of falls.





The results suggest that certain aspects of force platform data may have predictive value for subsequent falls, especially Computerized Dynamic Posturography - Commercial Medical Management Guideline various indicators of the lateral control of posture. However, the small number of studies available makes it difficult to draw definitive conclusions. (Piirtola, 2006) A validation study by Sataloff, et al. found that CDP was less specific than electronystagmography (ENG), but it provided more global insight into a patient's ability to maintain equilibrium under more challenging environmental circumstances.

CDP showed value in obtaining objective confirmation of an abnormality in some dizzy patients whose ENG findings are normal. (Sataloff, 2005) Patients with vestibular loss (11 with bilateral and 101 with unilateral vestibular loss) were investigated with posturography and compared to healthy subjects. The results showed that in static conditions, only bilateral vestibular loss patients had abnormal values compared to controls. In contrast, in dynamic eyes-closed conditions, both bilateral and unilateral patients could be differentiated from controls. Bilateral patients were unable to stand up without falling in both pitch and roll planes. Unilateral patients fell in the first week post-lesion and showed increased postural oscillations from the 2-week up to the 1-year post-lesion stage. The authors concluded that dynamic posturography could be a valuable tool for diagnosis and analysis of imbalance in patients with unilateral vestibular loss. While the investigators found value in CDP, this study lacked randomization and utilized unbalanced study groups. (Mbongo, 2005) A study of 75 patients investigated the use of CDP for clinical staging of vestibular diseases such as Meniere's disease. A statistically significant relationship between audiometric hearing threshold and CDP scores was found, especially in patients with advanced audiometric disease. CDP scores showed statistically significant variation with time elapsed since the last vertigo attack, allowing staging in terms of balance and posture. Non-randomization, lack of a control group and small sample size limit the usefulness of these results. (Soto, 2004) Artuso et al. conducted a validation study using 23 normal subjects and 16 patients with vestibular impairment. Normal subjects were studied during a state of simulated vertigo. Using EquiTest in combination with conventional methods, it was possible to differentiate malingerers from non-malingerers with 86.9% sensitivity and 89.7% specificity. Small sample size and poor study design limit the usefulness of these results. (Artuso, 2004) A Hayes report evaluated available evidence on CDP for diagnosing vestibular disorders. The review included one metaanalysis and 10 additional studies, many of which were non-comparative. The meta-analysis (n=1477) conducted by Di Fabio (1996), reported a sensitivity and specificity of approximately 50% for CDP used to diagnose vestibular disorders.

The Hayes review determined that the overall quality of the evidence on the efficacy of CDP for the evaluation of vestibular conditions is weak. There were no well-designed prospective, randomized clinical trials demonstrating the diagnostic utility of CDP compared with standard tests (Hayes, 2008).

Professional Societies American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) AAO-HNS recognizes that the following tests or treatments are medically indicated and appropriate in the evaluation or

treatment of persons with suspected balance or dizziness disorders:

- rotational chair step velocity testing

- harmonic acceleration testing

- vestibular rehabilitation therapy including the use of therapy devices

- dynamic platform posturography This statement is not part of a formal guideline and is not supported by clinical evidence. (AAO-HNS, 2007) Additional Search Terms Balance assessment, moving platform posturography, posture platform References and Resources Computerized Dynamic Posturography - Commercial Medical Management Guideline Resources American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) [Internet].

Posturography guideline. December 2007. Available at:

http://www.entnet.org/Practice/policyPosturography.cfm. Accessed April 2009.

Artuso A, Garozzo A, Contucci AM, et al. Role of dynamic posturography (Equitest) in the identification of feigned balance disturbances. Acta Otorhinolaryngol Ital. 2004 Feb;24(1):8-12.

Di Fabio RP. Meta-analysis of the sensitivity and specificity of platform posturography. Arch Otolaryngol Head Neck Surg. 1996;122(2):150-156.

ECRI Institute. Custom Hotline Response. Dynamic Posturography for Balance Disorders. March 2007. Archived.

Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and children: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000 Nov 28;55(10):1431-41. Available at: http://www.neurology.org/cgi/reprint/55/10/1431.pdf. Accessed April 2009.

Hayes, Inc. Technology Brief. Computerized Dynamic Posturography (CDP) for Diagnosis of Vestibular Disorders.

Lansdale, PA: Hayes, Inc.;June 2008.

Mbongo F, Patko T, Vidal PP, Vibert N, Tran Ba Huy P, de Waele C. Postural Control in Patients with Unilateral Vestibular Lesions Is More Impaired in the Roll than in the Pitch Plane: A Static and Dynamic Posturography Study.

Audiol Neurootol. 2005 May 30;10(5):291-302.

National Institute on Deafness and Other Communication Disorders (NIDCD) [Internet]. Balance disorders. January 2000.

Available at: http://www.nidcd.nih.gov/health/balance/balance_disorders.asp. Accessed April 2009 Piirtola M, Era P. Force platform measurements as predictors of falls among older people - a review. Gerontology.

2006;52(1):1-16.

Sataloff RT, Hawkshaw MJ, Mandel H, et al. Abnormal computerized dynamic posturography findings in dizzy patients with normal ENG results. Ear Nose Throat J. 2005 Apr;84(4):212-4.

Soto A, Labella T, Santos S, Rio MD, Lirola A, Cabanas E, Elhendi W. The usefulness of computerized dynamic posturography for the study of equilibrium in patients with Meniere's disease: correlation with clinical and audiologic data.

Hear Res. 2004 Oct;196(1-2):26-32.

Vestibular Disorders Association (VEDA) [Internet]. 2005. Available at: http://www.vestibular.org/. Accessed April 2009.

History/Updates Policy revised and renamed Computerized Dynamic Posturography. CMS information updated. Deleted 4/24/2009 the following CPT codes from the coding section: 92531, 92532, 92533, 92534, 92541, 92542, 92543, 92544, 92545, 92546, and 92547. Added ICD-9 diagnosis code 386.30 to the coding section. Policy Vestibular Function Testing (2008T0208E) archived.

Policy update. CMS and coding sections updated. Policy 2007T0208D archived.

7/2/2008 Policy updated. CMS and coding updated. Policy 2006T0208C archived.

12/6/2007 Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

–  –  –

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.

Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Computerized Dynamic Posturography - Commercial Medical Management Guideline TITLE: Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes Authorized By: Medical Management Guideline Committee

Adoption Date: 06/29/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.



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