This policy addresses diagnostic testing of the vestibular system. Vestibular
tests are tests of function, designed to identify a potential cause of balance
problems. Their purpose is to determine if there is a problem with the
vestibular portion of the brainstem and inner ear. Studies have documented
that in appropriate clinical settings, vestibular tests are more accurate than
clinical examination in identifying these disorders. The appropriate clinical
setting is described in this policy, including careful evaluation of the
patient, rationale for ordering high quality tests, clear communication
between the treating physician, consulting physician, and audiologist,
interpretation in light of the patient's case, and a plan for use of the
results in the patient's care. Diagnostic tests are not payable by Medicare
unless directly used in the patient's care.  
  
Vestibular function testing (VFT) is covered for the purpose of determining
the appropriate medical or surgical treatment of disorders in the vestibular
system. Other causes of balance problems can be found in other systems
including the senses of sight and touch, proprioception, muscle movement, and
from the integration of sensory input by the cerebellum. Causes of balance
problems can also include low blood pressure (BP), including postural
hypotension, asymmetrical gait due to pain, poor vision, poorly fitting shoes,
lack of concentration on safety in the immediate environment, anxiety, and
others.  
  
**Vestibular Testing**  
  
When a patient presents with complaints of balance problems, a thorough
history should be taken, a complete physical examination should be conducted
and a thorough review of medications should be completed. These expected
medical activities can often elicit a likely cause of the problem. A complete
picture of the patient is necessary before testing decisions can be made. The
tests that would identify a common cause of balance problems should be
conducted first, with progression in testing toward the least common cause of
balance problems.  
  
For example, an electrocardiogram (ECG) may show bradycardias or heartblocks.
A series of BP checks may show a pattern related to medication intake time.
The patient may be taking more (or less) medication than ordered because
he/she didn't understand the dosing instructions.  
  
If the provider sees or suspects a cause that would warrant a referral to a
specialist, a referral would be expected. For example, if an ECG showed
cardiac rhythm abnormalities, a referral to Cardiology would be expected. Any
neurological findings on physical examination could warrant a referral to a
neurologist, neurosurgeon, neurotologist, or similar specialist. Since
vestibular disorders are common causes of vertigo, imbalance and falling,
referral to specialists of these disorders may lead to more rapid diagnosis
and most appropriate use of vestibular testing.  
  
 **Treating Physician / Billing Provider**  
  
As noted above, VFTs are covered by Medicare only if they are clinically
necessary to diagnose vestibular disorders. A test is clinically necessary if
there is (A) appropriate evaluation and justification prior to the test and
(B) the results are used to manage the patient. A written order is required
from a physician who is treating the beneficiary; that is, the physician who
is (A) furnishing a consultation or (B) treating a beneficiary for a specific
medical problem and who uses the results in the management of the
beneficiary's specific medical problem. The treating physician has a
relationship with the beneficiary prior to the performance of the testing and
is treating the beneficiary for a specific medical problem for which the tests
are being ordered.  
  
 **Scope of Practice**  
  
Dizziness _may_ support the medical necessity for hearing tests in the initial
otolaryngologic evaluation of patients in whom general medical causes (anemia,
cardiovascular, metabolic, etc.) have been excluded. **However, since
dizziness is a vague complaint, a diagnosis of dizziness alone does not
qualify for coverage for VFT. There must be sufficient evaluation of the
patient that vestibular testing is likely to contribute directly to the
patient's therapy.** In those instances, full audiometric evaluation can be a
critical part of a full vestibular evaluation. The patient's record should
clearly document these circumstances.  
  
When the medical conditions requiring medical or surgical treatment are
already known by the physician, or are not under consideration, and the
diagnostic services are performed only to determine the need for or the
appropriate type of hearing aid, _the services are statutorily excluded from
Medicare coverage whether performed by a physician or nonphysician._  
  
**Hearing Testing**  
  
Standard hearing tests are not addressed in this policy. However, when a
_hearing_ test is ordered as a basis from which to decide to conduct
_vestibular_ testing (the provider may suspect a vestibular problem but wants
to rule out a pathology other than normal age-related hearing loss), the
hearing test will be covered.  
  
Diagnostic audiologic testing (including hearing and balance assessment
services) is covered when performed by a physician or a qualified audiologist.
An individual with a master's or doctoral degree in audiology and is licensed
as such by the relevant State is considered to be a qualified audiologist. In
addition to required licensure, audiologists are encouraged to obtain a
Certificate of Clinical Competence from the American Speech-Language-Hearing
Association (ASHA).  
  
In addition to the above qualification criteria, the following requirements
must also be met:

  1. The testing is ordered by a physician to obtain additional information to evaluate the need for or appropriate type of medical or surgical treatment for a hearing deficit or a medical problem; and

  2. The name of the physician ordering the testing is reported on the audiologist's claim (for example, testing performed by the audiologist to measure a hearing deficit or to identify the factors responsible for the deficit is covered when such services enable the physician to determine whether otologic surgery is indicated).

**Basic Audiometry:** Adequate testing requires an audiometer (device for
presenting sounds to the patient at precisely controlled intensity), a sound-
proof environment, a physician/audiologist, and a cooperative patient.