Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Intraoperative neurophysiologic monitoring (IOM) describes a variety of procedures that are used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, vascular and other surgeries that may place the nervous system at risk for injury. While it is clear that IOM can identify nervous system damage, there is little or no evidence that IOM can prevent damage in most situations.  All requests for on-site IOM require pre-authorization.

 The principal goal of intraoperative monitoring is the identification of nervous system impairment in the hope that prompt intervention will prevent permanent deficits. IOM techniques include use of somatosensory evoked potentials (SSEPs), electromyography (EMG), brainstem auditory evoked potentials (BAEPs), visual evoked potentials (VEPs), motor evoked potentials (MEP), or electroencephalogram (EEG).  Each technique may appropriately be used in certain limited surgical situations.  The situations in which QualChoice covers these techniques are detailed below.

 The technical components of this testing are part of the facility fee, just as are the technical components of radiological testing.  When continuous intraoperative neurophysiological monitoring is provided for the indications noted below by a physician other than the surgical team, and that physician is in personal attendance in the operating room, for the entire duration of monitoring, that component may be separately billed with the appropriate code. 

Remote IOM (from an off-site location) and any associated monitoring services are not covered.  This coverage exclusion is based on not meeting the standard of care for patients having high-risk procedures due to quality/safety concerns.   This is not comparable to a readily available on-site physician who is dedicated to monitoring a specific patient in the operating room without distractions from other patients (which is a covered service subject to prior authorization to confirm medical necessity).  You should check with your hospital and surgeon to avoid being surprised by a large, unexpected bill for remote IOM that is not covered.

1)    The professional component of intraoperative neurophysiological monitoring may be considered reimbursable as a separate service by QualChoice only when a licensed physician trained in clinical neurophysiology (e.g., neurologist, physiatrist), who is not a member of the surgical team performs the dedicated/exclusive monitoring while in attendance in the operating room (or on-site) throughout the pertinent portions of the procedure.  Pre-authorization is required for intraoperative neurophysiologic monitoring to ensure the appropriate criteria are met. 

2)    Services involving the use of remote IOM (95941 or G0453) are not covered.  This coverage exclusion is based on not meeting the standard of care for patients having high-risk procedures due to quality/safety concerns.  This is not comparable to a readily available on-site physician who is dedicated to monitoring a specific patient in the operating room without distractions from other patients (which is a covered service subject to prior authorization to confirm medical necessity).   

3)    The technical components of these services are considered to be included in the facility fee, just as the technical components of intraoperative radiological testing are. 

4)    Intraoperative somatosensory evoked potentials (SSEPs) with or without motor evoked potentials (MEPs) may be appropriate for:

a)    Spinal surgeries at levels C1-L2, where there is documentation of significant risk of injury to the spinal cord, such as correction of scoliosis, removal of spinal tumors, or surgery as a result of traumatic injury to the spinal cord;

b)    Intracranial surgical procedures, such as surgery for intracranial AV malformations, cerebral aneurysms, or surgery as a result of traumatic brain injury;

c)     Vascular surgeries that put the central nervous system at risk, such as surgery of the aortic arch or carotids where there is risk of cerebral ischemia, or distal aortic procedures where there is risk of spinal cord ischemia.

5)    Intraoperative electroencephalography (EEG) is considered medically necessary for monitoring cerebral function during carotid artery surgery or intracranial vascular surgical procedures.

6)    Intraoperative visual evoked potentials (VEPs) are considered medically necessary for any surgical procedure performed on or near the optic nerve, cortex, or chiasm.

7)    Intraoperative brainstem auditory evoked potentials (BAEPs) are considered medically necessary for any surgical procedure performed on or near the auditory nerve, inner ear, or brainstem.

8)    Intraoperative electromyography (EMG) may be appropriate for monitoring the facial nerve during any of the following intracranial surgeries:

a)    Decompression of the facial nerve

b)    Surgery for acoustic neuroma, congenital auricular lesions, or cranial based lesions

c)    Excision of facial neuromas

d)    Vestibular neurectomy for Meniere’s disease

Codes Used in This BI:

1)    Except for the combined use of MEP and SSEP in spinal surgery, QualChoice does not consider it to be medically necessary to use multiple intraoperative neurophysiological monitoring modalities during a single operative procedure, e.g., use of EEG along with SSEP during a carotid endarterectomy. 

2)    QualChoice considers intra-operative neuromonitoring during thyroid and parathyroid surgery experimental and investigational because its clinical value has not been established.

3)  QualChoice considers intra-operative EMG monitoring during hip replacement

surgery experimental and investigational because its clinical value has not been             established.

4)    QualChoice considers intra-operative EMG monitoring during lumbar fusion, discectomy, laminectomy, or laminotomy not medically necessary.

5)    Any other use of intraoperative neurophysiological monitoring is not considered medically necessary. 

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Addendum:

1.    Effective 09/01/2017:  Added language clarifying why remote intraoperative neurophysiologic monitoring does not meet the standard of care and is not covered.

2.    Effective 02/01/2018:  PA requirement for intraoperative neurophysiologic monitoring.

3.    Effective 05/01/2018: Language clarification that remote intraoperative monitoring, as a non-covered service, is not subject to medical necessity determinations.

4.    Effective 09/01/2018: Configuration update for additional remote monitoring code and for dual purpose test (limited auditory evoked potentials)

5.    Effective 01/01/2021: Deleted codes 92585 & 92586 and replaced with codes 92650, 92651, 92652 & 92653.  Added replaced codes to the search box as well as their descriptions in the codes used in this BI.