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Clinical Policy Bulletin:
Dehydration Testing for Endolymphatic Hydrops (Meniere's Disease)
Number: 0571


Policy

Aetna considers dehydration testing with glycerol, urea, or other osmotic diuretics to verify the suspicion of endolymphatic hydrops (Meniere's disease) medically necessary only in members with atypical presentations of this disease. 

Aetna considers dehydration testing experimental and investigational for other indications because its effectiveness has not been established.

See also CPB 0238 - Chronic VertigoCPB 0467 - Vestibular Autorotation Test (VAT)CPB 0514 - Meniere's Disease Surgery, and CPB 0564 - Electrocochleogram and Perilymphatic Pressure Measurement.



Background

Osmotic diuretics are able to reduce endolymphatic pressure and volume, and hence improve peripheral auditory and vestibular function.  After baseline audiometric testing, a glycerol, urea or other osmotic diuretic is administered.  Repeat audiometric testing is performed is performed at 3 hours (and sometimes at 1 and 2 hours) post-ingestion.  The test is considered positive if: (i) there is a 10 dB or more improvement at 2 or more frequencies (250 to 2,000 Hz), or (ii) there is a 12 % or greater improvement in speech discrimination scores.  The test is associated with a number of unpleasant side effects, including headache, nausea, thirst, diarrhea, emesis, diuresis, and dizziness.

Because dehydration tests are relatively specific for endolymphatic hydrops, they may be useful in confirming the presence of disease in patients with atypical presentations.  However, because the tests are relatively insensitive, they are not useful to rule out endolymphatic hydrops or as screening tests for the disease.

Although the tests appear relatively specific for endolymphatic hydrops, they are relatively insensitive.  Snyder (1974) reported the experience using the glycerol test in 122 patients with a combination of sensorineural hearing loss and tinnitus or vestibular symptoms, in whom endolymphatic hydrops was considered a diagnostic possibility.  Fifty percent of patients ultimately found to have endolymphatic hydrops had positive tests.  One false-positive was found among the positive tests.  In a series of 95 patients with Meniere's disease, Akioka et al (1990) found 47 % to have a positive glycerol dehydration test.  Stahle and Klockhoff (1986) reported 60 % of patients with Meniere's disease were found to have positive tests, and that positive tests were only found in ears with Meniere's disease.

Dehydration tests have not been proven to be useful in selecting patients with endolymphatic hydrops who are most likely to respond to surgery.  Some authors have suggested that patients with positive glycerol tests are more likely to have beneficial responses to endolymphatic sac decompression, but statistical proof of such a relationship is lacking.

Whether a Meniere's disease patient will have a positive test or not seems to depend in part on the phase of the disease.  Tests are more likely negative very early and very late in the course of disease, although the stage of the disease is not predictable from the results of the dehydration testing.

Critics of dehydration testing note that the test is unpleasant, not adequately sensitive, impractical, and subject to significant placebo effects.  According to Fagan (1999), dehydration studies are little used these days because they are unpleasant and time consuming.  There is only anecdotal evidence that positive responders to dehydration tests may be more likely to respond to endolymphatic sac decompression.  Some investigators have found that the results of dehydration testing are highly affected by suggestion to the patients as to what they should expect.  These investigators suggest that the use of the dehydration test to select patients for surgery risks induces a bias toward more placebo responders.

In a critical review of diagnostic testing in endolymphatic hydrops, Arts et al (1997) concluded: "At this point, the clinical use of dehydration testing is unclear at best.  Despite many legitimate questions with regard to its practicality and sensitivity, there is considerable evidence that a real phenomenon, specific for endolymphatic hydrops, underlies this test.  Given this, the test may be helpful in verifying the suspicion of endolymphatic hydrops in patients with atypical presentations.  It is unlikely, however, that the choice of therapy will be altered by the results of this test in many instances".

An UpToDate review on “Meniere disease” (Dinces and Rauch, 2014) does not mention the use of dehydration testing as a diagnostic tool.

Note: Osmotic diuretics such as urea and isosorbide that can be taken orally have also been used as treatment for endolymphatic hydrops.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
There is no specific code for dehydration testing for endolymphatic hydrops:
Other CPT codes related to the CPB:
69805 - 69806
ICD-9 codes covered if selection criteria are met:
386.00 - 386.04 Meniere's disease
388.30 - 388.32 Tinnitus
389.10 - 389.9 Hearing loss
386.10 - 386.19 Other and unspecified peripheral vertigo
386.30 - 386.35 Labyrinthitis
386.40 - 386.48 Labyrinthine fistula
386.50 - 386.58 Labyrinthine dysfunction
386.8 Other disorders of labyrinth
780.4 Dizziness and giddiness
781.3 Abnormality of gait


The above policy is based on the following references:
  1. Stahle J. Medical treatment of fluctuant hearing loss in Meniere's disease. Am J Otol. 1984;5(6):529-533.
  2. Angelborg C, Klockhoff I, Stahle J. Urea and hearing in patients with Meniere's disease. Scand Audiol. 1977;6(3):143-146.
  3. Arts HA, Kileny PR, Telian SA. Diagnostic testing for endolymphatic hydrops. Otolaryngol Clin North Am. 1997;30(6):987-1005.
  4. Snyder JM. Extensive use of a diagnostic test for Meniere disease. Arch Otolaryngol. 1974;100:360-365.
  5. Stahle J, Klockhoff I. Diagnostic procedures, differential diagnosis, and general conclusions. In: Controversial Aspects of Meniere Disease. CR Pfaltz, ed. New York, NY: Thieme Inc.; 1986:71-86.
  6. Akioka K, Fujita N, Kitaoku Y, et al. A clinical study of the diagnosis of endolymphatic hydrops aspect of Meniere's disease. In: Meniere's Disease. M Kitahara, ed. Toronto, ON: Springer Verlag; 1990:125-132.
  7. Thomsen J, Vesterhauge S. A critical evaluation of the glycerol test in Meniere's disease. J Otolaryngol. 1979;8:145-150.
  8. TrailBlazer Health Enterprises. Urea dehydration test. Texas Medicare Part B Local Medical Review Policy. Dallas, TX: Trailblazer; revised June 26, 2000. Available at: http://www.the-medicare.com/lmrp/tx/ureadehy.asp. Accessed May 7, 2001.
  9. Sakashita T, Shibata T, Yamane H, Hikawa C. Changes in input/output function of distortion product otoacoustic emissions during the glycerol test in Meniere's disease. Acta Otolaryngol Suppl. 2004;(554):26-29.
  10. Magliulo G, Cuiuli G, Gagliardi M, et al. Vestibular evoked myogenic potentials and glycerol testing. Laryngoscope. 2004;114(2):338-343.
  11. Magliulo G, Parrotto D, Gagliardi S, et al. Vestibular evoked periocular potentials in Meniere's disease after glycerol testing. Ann Otol Rhinol Laryngol. 2008;117(11):800-804.
  12. Kriukov AI, Kunel'skaia NL, Garov EV, et al. Diagnostics of endolymphatic hydrops. Vestn Otorinolaringol. 2013;(2):4-7.
  13. Dinces EA, Rauch SD. Meniere disease. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna 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 Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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