Medical Policy

Effective Date:01/01/2013 Title:Intraoperative Neurophysiologic Monitoring
Revision Date:09/01/2018 Document:BI381:00
CPT Code(s):G0453, 92585, 92586, 92650, 92651, 92652, 92653, 95822, 95829, 95860, 95861, 95863, 95864, 95867, 95868, 95870, 95905, 95907-95913, 95925-95930, 95933, 95937-95941, 95955
Public Statement

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.

Medical Statement

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:

 

92585

Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive (code deleted eff 01-01-2021)

92586

Auditory evoked potentials for evoked response; Limited  (for intraoperative monitoring or for newborn screening) (code deleted eff 01-01-2021)

95822

Electroencephalogram (EEG); recording in coma or sleep only

95829

Electrocardiogram at surgery (separate procedure)

95860

Needle electromyography; one extremity with or without related paraspinal areas

95861

Needle electromyography; two extremities with or without related paraspinal areas

95863

Needle electromyography; three extremities with or without related paraspinal areas

95864

Needle electromyography; four extremities with or without related paraspinal areas

95867

Needle electromyography; cranial nerve supplied muscle(s), unilateral

95868

Needle electromyography; cranial nerve supplied muscles, bilateral

95870

Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters

95905

Nerve conduction studies, using preconfigured array

95907

Nerve conduction studies; 1-2 studies

95908

Nerve conduction studies; 3-4 studies

95909

Nerve conduction studies; 5-6 studies

95910

Nerve conduction studies; 7-8 studies

95911

Nerve conduction studies; 9-10 studies

95912

Nerve conduction studies; 11-12 studies

95913

Nerve conduction studies; 13 or more studies

95925

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

95926

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs

95927

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head

95928

Central motor evoked potential study (transcranial motor stimulation); upper limbs

95929

Central motor evoked potential study (transcranial motor stimulation); lower limbs

95930

Visual evoked potential (VEP) testing central nervous system, checkerboard or flash

95933

Orbicularis oculi (blink) reflex, by electro diagnostic testing

95937

Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method

95938

Short-latency somatosensory evoked potential study, in upper and lower limbs

95939

Central motor evoked potential study, in upper and lower limbs

95940

Intraoperative neurophysiological monitoring in the OR

95941

Intraoperative neurophysiological monitoring remotely, > 1 patient, each hour

95955

Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)

G0453

Intraoperative neurophysiologic monitoring remotely, one patient, each 15 mins

92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis (new code eff 01-01-2021)

92651

Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report (new code eff 01-01-2021)

92652

Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report (new code eff 01-01-2021)

92653

Auditory evoked potentials; neurodiagnostic, with interpretation and report (new code eff 01-01-2021)

Limits

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. 

Reference

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5)    Harner SG, Daube JR, Ebersold MJ, Beatty CW. Improved preservation of facial nerve function with use of electrical monitoring during removal of acoustic neuromas.

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66) Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for

intraoperative neurophysiological monitoring in spine surgery: Does it make a

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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.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.