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CPT®
69915

CPT® Code 69915

Official Description

Vestibular nerve section, translabyrinthine approach

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

Vestibular nerve section, performed via a translabyrinthine approach, is a surgical procedure aimed at alleviating severe recurrent episodes of vertigo. This condition can significantly impact a patient's quality of life, leading to debilitating symptoms that may not respond to conservative treatments. The procedure involves a meticulous surgical technique that begins with a C-shaped incision made above the ear, extending around the back of the ear. This incision allows access to the mastoid bone, where a complete mastoidectomy is conducted using specialized high-speed drills and various burs to remove bone and create a clear pathway to the inner ear structures. The surgery entails careful dissection to expose critical anatomical landmarks, including the facial nerve, the internal auditory canal, and the vestibular nerves. The goal of the procedure is to section the superior and inferior vestibular nerves, which are responsible for transmitting balance information to the brain, thereby interrupting the pathways that contribute to vertigo. The surgical site is then irrigated, and the incision is closed in layers to promote healing and minimize complications.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The vestibular nerve section via a translabyrinthine approach is indicated for patients experiencing:

  • Severe recurrent attacks of vertigo that are unresponsive to conservative management and significantly impair daily functioning.

2. Procedure

The procedure involves several critical steps to ensure successful access and sectioning of the vestibular nerves:

  • Step 1: Incision A C-shaped incision is initiated above the ear and is extended around the back of the ear to provide adequate access to the surgical site.
  • Step 2: Mastoidectomy The mastoid bone is entered, and a complete mastoidectomy is performed using a high-speed drill and various burs to remove the necessary bone and create a clear view of the inner ear structures.
  • Step 3: Identification of Structures The antrum and incus are identified during the dissection, allowing the surgeon to navigate the complex anatomy of the ear.
  • Step 4: Skeletonization of the Sigmoid Sinus Bone overlying the sigmoid sinus is carefully removed, and the sinus is skeletonized to prevent injury during the procedure.
  • Step 5: Exposure of the Dura Bone is removed posteriorly over the suboccipital dura to facilitate access to the internal auditory canal.
  • Step 6: Labyrinthectomy A labyrinthectomy is performed to remove the inner ear structures, allowing for better visualization of the vestibular nerves.
  • Step 7: Protection of the Facial Nerve The facial nerve is exposed and carefully protected throughout the procedure to avoid damage.
  • Step 8: Sectioning of the Superior Vestibular Nerve Dissection continues to the ampullated end of the internal auditory canal, where the superior vestibular nerve is located. This nerve is then cut (sectioned) to interrupt its function.
  • Step 9: Identification and Sectioning of the Inferior Vestibular Nerve The inferior vestibular nerve is identified as it exits the lateral end of the internal auditory canal and is also sectioned to further alleviate vertigo symptoms.
  • Step 10: Wound Closure After the nerves have been sectioned, the surgical wound is irrigated to reduce the risk of infection, and the incision is closed in layers to promote optimal healing.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications, such as infection or cerebrospinal fluid leaks. Patients may experience some degree of recovery time, during which they should be advised on activity restrictions and follow-up appointments to assess healing and symptom relief. Pain management and wound care instructions will also be provided to ensure a smooth recovery process.
Short Descr INCISE INNER EAR NERVE
Medium Descr VESTIBULAR NRV SECTION TRANSLABYRINTHINE APPR
Long Descr Vestibular nerve section, translabyrinthine approach
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 26 - Other therapeutic ear procedures
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
LT Left side (used to identify procedures performed on the left side of the body)
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Pre-1990 Added Code added.
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