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Dynamic Posturography

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 02.01.08 
Original Effective Date: December 2000 
Reviewed: July 2016 
Revised: August 2015 


Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description: 

Computerized Dynamic Posturography (CDP), (also known as dynamic posturography, balance board testing, equilibrium platform testing (EPT), and moving platform posturography), is a unique assessment technique used to objectively quantify and differentiate among the wide variety of possible sensory, motor and central adaptive impairments to balance control.

 

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.  Results of 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 diagnose pathology or be used to localize the site of a lesion.

 

CDP comprises three functional test protocols:

  • Sensory Organization Test (SOT): The SOT protocol objectively identifies abnormalities in the patient’s use of the three sensory systems that contribute to postural control: somatosensory, visual and vestibular. During the SOT, useful information delivered to the patient’s eyes, feet and joints is effectively eliminated through calibrated sway referencing of the support surface and/or visual surround, which tilt to directly follow the patient’s anteroposterior body sway. By controlling the usefulness of the sensory (visual and proprioceptive) information through sway referencing and/or eyes opened/closed conditions, the SOT protocol systematically eliminates useful visual and/or support surface information and creates sensory conflict situations. These conditions isolate vestibular balance control, as well as stress the adaptive responses of the central nervous system. In short, patients may display either an inability to make effective use of individual sensory systems, or inappropriate adaptive responses, resulting in the use of inaccurate sense(s).
  • Motor Control Test (MCT): The MCT assesses the ability of the automatic motor system to quickly recover following an unexpected external disturbance. Sequences of small, medium or large platform translations (scaled to the patient’s height) in forward and backward directions elicit automatic postural responses.
    • Functional implications: Automatic postural responses are the first line of defense against a fall following unexpected external disturbances to balance. To be effective in this capacity, responses must be timely and well coordinated between the two legs. As response latencies increase and/or amplitudes decrease outside normal ranges, effectiveness is reduced and patients tend to sway farther in response to disturbances. Patient’s with abnormally strong responses tend to over-correct and oscillate back and forth. When responses are asymmetrical between the two legs, patients are at increased risk for instability during tasks such as walking and reaching when the less effective leg is the primary means of postural support.
    • When combined with the sensory organization test (SOT), the MCT results are useful in differentiating among normal responses, true pathological conditions and exaggerated sway responses.
    • Automatic response latency information is utilized as part of the diagnostic process. Prolonged latencies are evidence of musculoskeletal/biomechanical problems and/or pathology within the long loop pathways including the peripheral nerves, ascending and descending spinal pathways, and brain structures. When prolonged latencies are documented by MCT, the EMG component is helpful in further localizing the deficit within the peripheral nerves or central pathways.
  • Adaptation Test (ADT): The ADT assesses a patient’s ability to minimize sway when exposed to surface irregularities and unexpected changes in support surface inclination.  Encounters with surface irregularities and changes in inclination of the support surface are common in daily life activities. Patients performing abnormally in the ADT tend to have difficulty under these conditions.

Regulatory Status
The NeuroCom EquiTest® is a dynamic posturography device that received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA). Other dynamic posturography device makers include Micromedical Technology, Metitur, and Vestibular Technologies.

 

Summary

Based on the peer reviewed literature the evidence for computerized dynamic posturography in inidividuals who have suspected balance disorders includes technical performance studies, cross-sectional comparisons of results in patients with balance disorders and healthy controls, and retrospective case series reporting outcomes of patients assessed with dyanamic posturography as part of clinical care. There are no generally accepted reference standards for computerized dynamic posturography (CDP), which makes it difficult to determine how the results can be applied in clinical care. There is a lack of evidence on the performance characteristics of this test for clinically important conditions, such as identifying patients who are at risk of falls. There are no studies demonstrating the clinical utility of the test that would lead to changes in the management that improve health outcomes (e.g. symptoms and function). The evidence is insufficient to determine the effects of this technology on health outcomes.and therefore, computerized dyanamic posturography (CDP) is considered investigational for all indications.


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Prior Approval: 

 

Not applicable


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Policy: 

Computerized Dynamic Posturography (CDP) is considered investigational for all indications. 

 

Based on the peer reviewed literature there are no generally accepted reference standards for dynamic posturography which makes it difficult to determine how the results can be applied to clinical care. There are no studies that demonstrate the clinical utility of the test that leads to changes in management and improves health outcomes. Therefore, computerized dynamic posturography (CDP) testing is considered investigational for all indications.





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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 92548 Computerized dynamic posturography

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Selected References: 

  • Furman JM. Role of posturography in the management of vestibular patients.  1995;112:8-15.
  • Allum JHJ, Shepard NT. An overview of the clinical use of dynamic posturography in the differential diagnosis of balance disorders. Journal of Vestibular Research 1999;9:223-252.
  • Evans, MK Krebs DE. Posturography does not test vestibulospinal function. Otolaryngol Head Neck Surg. 1999 Feb; 120(2):164-73. 
  • Ruckenstein MJ, Shepard NT. Balance Function Testing; A rational approach. Otolaryngologic Clinics of North America; Vol.33;No3;Jun 2000.
  • Amin M, Girardi M, Konrad HR, Hughes L. A comparison of electronystagmography results with posturography findings from the Balance trak 500. Otol Neurol. 2002 Jul;23(4);488-93.
  • Morgan SS, Beck WG, Dobie RA. Can posturography identify malingerers? Otol Neurol 2002 Mar;23(2):214-7.
  • ECRI Institute. Dynamic Posturography for Balance Disorders. ECRI InstituteExternal Site Custom Hotline Response. 3/20/2007.
  • ECRI Institute. Dynamic Posturography for Balance Disorders. Plymouth Meeting (PA): ECRI InstituteExternal Site: 2007 March 20. 9p. [ECRI custom hotline response].
  • Ebersbach, G & Gunkel, M. Posturography reflects clinical imbalance in Parkinson's disease. Mov Disord. 2010 Dec 13. [Epub ahead of print]
  • 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 Apr;91(4):598.
  • Balaguer Garcia R, Pitarch Corresa S, Baydal Bertomeu JM, Morales Suarez-Varela MM. Static posturography with dynamic tests. Usefulness of biomechanical parameters in assessing vestibular patients. Acta Otorrinolaringol Esp. 2012 Sep-Oct;63(5):332-8. 
  • Ganesan M, Pasha SA, Pal PK, Yadav R, Gupta A. Direction specific preserved limits of stability in early progressive supranuclear palsy: a dynamic posturographic study. Gait Posture. 2012 Apr;35(4):625-9.
  • NeuroCom. Computerized Dynamic Posturography (CDP). Balance and MobilityExternal Site
  • American Academy of Otolaryngology-Head and Neck Surgery Foundation.Position Statement: Posturography. www.entnet.org
  • Bhattacharyya N, Baugh RF, Orvidas L, et al. American Academy of Otolaryngology-Head Neck, Surgery Foundation Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 Suppl 4):S47-81.
  • Pang MY, Lam FM, Wong GH, et al. Balance performance in head-shake computerized dynamic posturography: aging effects and test-retest reliability. Phys Ther. Feb 2011;91(2):246-253. PMID 21148260
  • 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. Apr 2011;33(4):594-599. PMID 21333541
  • 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. PMID 25878185
  • 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. Apr 2012;35(4):625-629. PMID 22225854
  • Lee JM, Koh SB, Chae SW, et al. Postural instability and cognitive dysfunction in early Parkinson's disease. Can J Neurol Sci. Jul 2012;39(4):473-482. PMID 22728854
  • Pierchala K, Lachowska M, Morawski K, et al. Sensory Organization Test outcomes in young, older and elderly healthy individuals - preliminary results. Otolaryngol Pol. Jul 2012;66(4):274-279. PMID 22890532
  • Biggan JR, Melton F, Horvat MA, et al. Increased load computerized dynamic posturography in prefrail and nonfrail community-dwelling older adults. J Aging Phys Act. Jan 2014;22(1):96-102. PMID 23416307
  • 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. PMID 26504611
  • 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. PMID 24076084

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Policy History: 

 

July 2016 - Annual Review, Policy Renewed

August 2015 - Annual Review, Policy Revised

September 2014 - Annual Review, Policy Renewed

October 2013 - Annual Review, Policy Renewed

December 2012 - Annual Review, Policy Renewed

December 2011 - Annual Review, Policy Renewed

December 2010 - Annual Review, Policy Renewed


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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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