Medical Policy

Effective Date:08/07/2013	Title:Gait Analysis
Revision Date:10/01/2015	Document:BI412:00
CPT Code(s):96000-96004
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. Gait analysis, or motion analysis, is the quantitative laboratory assessment of coordinated muscle function, typically requiring a dedicated facility and staff. This procedure is covered for patients with cerebral palsy or spina bifida who have disorders of gait.
Medical Statement
Gait analysis is considered medically necessary and is covered for either the pre-operative or post-operative assessment of patients with cerebral palsy or spina bifida who have disorders of gait. Codes Used in This Policy: 96000 Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; 96001 Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; with dynamic plantar pressure measurements during walking 96002 Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles 96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle 96004 Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
Limits
Intentially left empty
Reference
Cimolin V, Galli M, Vimercati SL et al. Use of the Gait Deviation Index for the assessment of gastrocnemius fascia lengthening in children with cerebral palsy. Res Dev Disabil 2011; 32(1): 377-81. Desloovere K, Molenaers G, et al. Do dynamic and static clinical measurements correlate with gait analysis parameters in children with cerebral palsy? Gait Posture, 2006; 24(3):302-13. Gabrieli AP, et al. Gait analysis in low lumbar myelomeningocele patients with unilateral hip dislocation or subluxation. J Pediatr Orthop, 2003; 23(3):330. Noonan KJ, Halliday S, et al. Interobserver variability of gait analysis in patients with cerebral palsy. J Pediatr Orthop, 2003; 23(3):279-87. Swaroop VT and Dias L. Orthopedic management of spina bifida. J Child Orthop, 2009; 3:441-449. Thomson JD and Segal LS. Orthopedic management of spina bifida. Dev Dis Res Rev 2010; 16:96-103 Wren TA, Otsuka NY, Bowen RE et al. Outcomes of lower extremity orthopedic surgery in ambulatory children with cerebral palsy with and without gait analysis: Results of a randomized controlled trial. Gait Posture 2012 [Epub ahead of print]. Wren TA, Woolf K, Kay RM. How closely do surgeons follow gait analysis recommendations and why? J Pediatr Orthop B, 2005; 14(3):202-5.
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.