Highmark Commercial Medical Policy - Pennsylvania


 
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Medical Policy: M-13-035
Topic: Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
Section: Diagnostic Medical
Effective Date: October 1, 2017
Issue Date: November 13, 2017
Last Reviewed: March 2017

Intraoperative neurophysiologic monitoring (IONM) describes a variety of procedures that have been used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Intraoperative monitoring (IONM), includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography (EMG) of cranial nerves, electroencephalogram (EEG), and electrocorticography (ECoG), may be considered medically necessary for ANY of the following procedures:

  • Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia; or
  • Resection of epileptogenic brain tissue or tumor; or
  • Resection of brain tissue close to the primary motor cortex and requiring brain mapping; or
  • Protection of cranial nerves during:
    • Resection of tumors involving the cranial nerves; or
    • Cavernous sinus tumors; or
    • Microvascular decompression of cranial nerves: or
    • Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum; or
    • Oval or round window graft; or
  • Endolymphatic shunt for Meniere's disease; or
  • Vestibular section for vertigo; or
  • Correction of scoliosis or deformity of spinal cord involving traction of the cord; or
  • Protection of spinal cord where work is performed in proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions; or
  • Spinal instrumentation requiring pedicle screws or distraction; or
  • Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk; or
  • Spinal cord tumors and spinal fractures (with the risk of cord compression); or
  • Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves; or
  • Surgery or embolization for intracranial arteriovenous malformations (AVMs); or
  • Embolization of bronchial artery AVMs or tumors; or
  • Surgery for arteriovenous malformation of spinal cord; or
  • Cerebral vascular aneurysms; or
  • Surgery for intractable movement disorders; or
  • Arteriography, during which there is a test occlusion of the carotid artery; or
  • Circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., coronary artery bypass grafting (CABG), ventricular aneurysms); or
  • Distal aortic procedures, where there is risk of ischemia to spinal cord; or
  • Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks; or
  • Basal ganglia movement disorders; or
  • Surgery as a result of traumatic injury to spinal cord/brain; or
  • Deep brain stimulation; or
  • Certain thyroid surgeries when there is;
    • Total removal of a complete lobe of the thyroid; or
    • Removal of the entire gland; or
    • Re-entry (re-operation) to a prior surgical field where scar tissue obscures the visual path of the recurrent laryngeal nerve.

Intraoperative neurophysiologic monitoring for any other procedure not listed above is considered not medically necessary.

Procedure Codes
92585, 92586, 95829, 95860, 95861, 95863, 95864, 95867, 95868, 95907, 95908, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95928, 95929, 95937, 95938, 95939, 95940, 95941, 95955, G0453



Neurophysiological studies

Neurophysiological studies may be reimbursed individually whether performed independently or in conjunction with each other.  However, if a provider reports any neurophysiological studies in addition to comprehensive evoked response audiometry, the charges should be combined and processed under code 92585. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Intraoperative Neurophysiology Monitoring (IONM)

Intraoperative neurophysiology monitoring should be reported under procedure code 95940, 95941, G0453 regardless of the specific monitoring performed (e.g., brainstem auditory evoked response, somatosensory evoked potentials, etc.). If any of the testing codes for neurophysiological monitoring are reported in conjunction with 95940, 95941, G0453 the services should be combined and processed under 95940, 95941, G0453. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Reimbursement is limited to either 95940 (continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary procedure) or 95941 (continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)) per date of service.

Procedure Codes
92585, 95940, 95941, G0453



Intraoperative monitoring of visual-evoked potentials is considered experimental/investigational and therefore non-covered, due to a lack of scientific peer reviewed literature.

Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary.

Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental/investigational due to a lack of scientific peer reviewed literature and therefore non-covered.

Procedure Codes
0464T, 95930


Place of Service: Inpatient/Outpatient


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

  • Link to Provider Resource Center for the Medical Policy Update
  • 06/2015, New Guidelines Established for Medical Policy M-13, Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring.)
    04/2017, Coverage criteria updated for Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring.)





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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Room 509F, HHH Building
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