HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
M-13-047
Topic:
Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
Section:
Diagnostic Medical
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
August 2022
 
 

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.

Policy Position

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

  • When performed by an operator who is certified by the American Board of Medical Specialties (ABMS); and
  • Monitoring only one (1) procedure at a time; and
  • For ANY of the following procedures:

o   Aortic arch, its branch vessels, or thoracic aorta surgery, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia; or

o   Aortic procedures, distal, where there is risk of ischemia to spinal cord; or

o   Arteriovenous malformations (AVMs), surgery or embolization for intracranial AVMs; or

o   Basal ganglia movement disorders; or

o   Brain, deep stimulation; or

o   Brain, resection of epileptogenic tissue or tumor; or

o   Brain, resection of tissue close to the eloquent brain cortex and requiring brain mapping; or

o   Brain surgery as a result of traumatic injury; or

o   Bronchial artery arteriovenous malformations or tumors, embolization of; or

o   Carotid artery arteriography, during which there is a test occlusion of the carotid artery; or

o   Cerebral vascular aneurysms; or

o   Circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., coronary artery bypass grafting (CABG), ventricular aneurysms); or

o   Cranial nerve protection during:

o   Resection of tumors involving the cranial nerves; or

o   Cavernous sinus tumors; or

o   Microvascular decompression of cranial nerves; or

o   Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum; or

o   Oval or round window graft; or

o   Endolymphatic shunt for Meniere's disease; or

o   Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks; or

o   Movement disorders, surgery for intractable movement disorders; or

o   Peripheral nerves, neuromas of the brachial plexus, when there is risk to major sensory or motor nerves; or

o   Responsive neurostimulation for epilepsy; or

o   Spinal cord, arteriovenous malformation surgery; or

o   Spinal cord, correction of scoliosis or deformity of the spinal cord involving traction of the cord; or

o   Spinal cord, 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

o   Spinal cord, protection where work is performed in proximity to cord and nerve roots as in the placement of new instrumentation or removal of old hardware or where there have been numerous interventions; or

o   Spinal cord surgery as a result of traumatic injury; or

o   Spinal cord tumors and spinal fractures (with the risk of cord compression); or

o   Spinal instrumentation requiring pedicle screws, disc arthroplasty or distraction; or

o   Vestibular section for vertigo.

IONM not meeting the criteria as indicated in this policy is considered not medically necessary.

0464T

92650

92651

92652

92653

95829

95860

95861

95863

95864

95867

95868

95907

95908

95910

95911

95912

95913

95925

95926

95927

95928

95929

95937

95938

95939

95940

95955

G0453

 

 

 

 

 

 




IONM performed for more than one procedure at a time is considered not medically necessary.

95941

 

 

 

 

 

 




IONM of the recurrent laryngeal nerve may be considered medically necessary in individuals undergoing:

  • Anterior cervical spine surgery associated with any of the following increased risk situations:
    • Multilevel anterior cervical discectomy and fusion; or
    • Preexisting recurrent laryngeal nerve pathology, when there is residual function of the recurrent laryngeal nerve; or
    • Prior anterior cervical surgery, particularly revision anterior cervical discectomy and fusion, revision surgery through a scarred surgical field, reoperation for pseudarthrosis, or revision for failed fusion.
  • High-risk thyroid or parathyroid surgery, including:
    • Repeat thyroid or parathyroid surgery; or
    • Retrosternal or giant goiter; or
    • Surgery for cancer; or
    • Thyrotoxicosis; or
    • Thyroiditis; or
    • Total thyroidectomy.

IONM of the recurrent laryngeal nerve not meeting the criteria as indicated in this policy is considered experimental and investigational and therefore, non-covered because the safety and /or effectiveness of this service cannot be established by the available peer-reviewed literature

95865

 

 

 

 

 

 




IONM of visual-evoked potentials is considered experimental/investigational and therefore, non-covered because the safety and /or effectiveness of this service cannot be established by the available peer-reviewed literature.

95930

 

 

 

 

 

 




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S06.5X0A

S06.5X0D

S06.5X0S

S06.5X1A

S06.5X1D

S06.5X1S

S06.5X2A

S06.5X2D

S06.5X2S

S06.5X3A

S06.5X3D

S06.5X3S

S06.5X4A

S06.5X4D

S06.5X4S

S06.5X5A

S06.5X5D

S06.5X5S

S06.5X6A

S06.5X6D

S06.5X6S

S06.5X7A

S06.5X8A

S06.5X9A

S06.5X9D

S06.5X9S

S06.6X0A

S06.6X0D

S06.6X0S

S06.6X1A

S06.6X1D

S06.6X1S

S06.6X2A

S06.6X2D

S06.6X2S

S06.6X3A

S06.6X3D

S06.6X3S

S06.6X4A

S06.6X4D

S06.6X4S

S06.6X5A

S06.6X5D

S06.6X5S

S06.6X6A

S06.6X6D

S06.6X6S

S06.6X7A

S06.6X8A

S06.6X9A

S06.6X9D

S06.6X9S

S06.890A

S06.890D

S06.890S

S06.891A

S06.891D

S06.891S

S06.892A

S06.892D

S06.892S

S06.893A

S06.893D

S06.893S

S06.894A

S06.894D

S06.894S

S06.895A

S06.895D

S06.895S

S06.896A

S06.896D

S06.896S

S06.897A

S06.898A

S06.899A

S06.899D

S06.899S

S06.9X0A

S06.9X0D

S06.9X0S

S06.9X1A

S06.9X1D

S06.9X1S

S06.9X2A

S06.9X2D

S06.9X2S

S06.9X3A

S06.9X3D

S06.9X3S

S06.9X4A

S06.9X4D

S06.9X4S

S06.9X5A

S06.9X5D

S06.9X5S

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X7A

S06.9X8A

S06.9X9A

S06.9X9D

S06.9X9S

S12.000A

S12.000B

S12.000S

S12.001A

S12.001B

S12.001S

S12.01XS

S12.02XS

S12.030S

S12.031S

S12.040S

S12.041S

S12.090S

S12.091S

S12.100A

S12.100B

S12.100S

S12.101A

S12.101B

S12.101S

S12.110A

S12.110B

S12.110S

S12.111A

S12.111B

S12.111S

S12.112A

S12.112B

S12.112S

S12.120A

S12.120B

S12.120S

S12.130A

S12.130B

S12.130S

S12.131A

S12.131B

S12.131S

S12.14XA

S12.14XB

S12.14XS

S12.150A

S12.150B

S12.150S

S12.151A

S12.151B

S12.151S

S12.190A

S12.190B

S12.190S

S12.191A

S12.191B

S12.191S

S12.200A

S12.200B

S12.200S

S12.201A

S12.201B

S12.201S

S12.230A

S12.230B

S12.230S

S12.231A

S12.231B

S12.231S

S12.24XA

S12.24XB

S12.24XS

S12.250A

S12.250B

S12.250S

S12.251A

S12.251B

S12.251S

S12.290A

S12.290B

S12.290S

S12.291A

S12.291B

S12.291S

S12.300A

S12.300B

S12.300S

S12.301A

S12.301B

S12.301S

S12.330A

S12.330B

S12.330S

S12.331A

S12.331B

S12.331S

S12.34XA

S12.34XB

S12.34XS

S12.350A

S12.350B

S12.350S

S12.351A

S12.351B

S12.351S

S12.390A

S12.390B

S12.390S

S12.391A

S12.391B

S12.391S

S12.400A

S12.400B

S12.400S

S12.401A

S12.401B

S12.401S

S12.430A

S12.430B

S12.430S

S12.431A

S12.431B

S12.431S

S12.44XA

S12.44XB

S12.44XS

S12.450A

S12.450B

S12.450S

S12.451A

S12.451B

S12.451S

S12.490A

S12.490B

S12.490S

S12.491A

S12.491B

S12.491S

S12.500A

S12.500B

S12.500S

S12.501A

S12.501B

S12.501S

S12.530A

S12.530B

S12.530S

S12.531A

S12.531B

S12.531S

S12.54XA

S12.54XB

S12.54XS

S12.550A

S12.550B

S12.550S

S12.551A

S12.551B

S12.551S

S12.590A

S12.590B

S12.590S

S12.591A

S12.591B

S12.591S

S12.600A

S12.600B

S12.600S

S12.601A

S12.601B

S12.601S

S12.630A

S12.630B

S12.630S

S12.631A

S12.631B

S12.631S

S12.64XA

S12.64XB

S12.64XS

S12.650A

S12.650B

S12.650S

S12.651A

S12.651B

S12.651S

S12.690A

S12.690B

S12.690S

S12.691A

S12.691B

S12.691S

S12.9XXA

S12.9XXD

S12.9XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118D

S14.118S

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128D

S14.128S

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151S

S14.152A

S14.152S

S14.153A

S14.153S

S14.154A

S14.154S

S14.155A

S14.155S

S14.156A

S14.156S

S14.157A

S14.157S

S14.158A

S14.158S

S14.159A

S14.159S

S14.2XXA

S14.2XXS

S14.3XXA

S14.3XXS

S14.4XXA

S14.4XXS

S14.5XXA

S14.5XXS

S22.000A

S22.000B

S22.000S

S22.001A

S22.001B

S22.001S

S22.002A

S22.002B

S22.002S

S22.008A

S22.008B

S22.008S

S22.009A

S22.009B

S22.009S

S22.010A

S22.010B

S22.010S

S22.011A

S22.011B

S22.011S

S22.012A

S22.012B

S22.012S

S22.018A

S22.018B

S22.018S

S22.019A

S22.019B

S22.019S

S22.020A

S22.020B

S22.020S

S22.021A

S22.021B

S22.021S

S22.022A

S22.022B

S22.022S

S22.028A

S22.028B

S22.028S

S22.029A

S22.029B

S22.029S

S22.030A

S22.030B

S22.030S

S22.031A

S22.031B

S22.031S

S22.032A

S22.032B

S22.032S

S22.038A

S22.038B

S22.038S

S22.039A

S22.039B

S22.039S

S22.040A

S22.040B

S22.040S

S22.041A

S22.041B

S22.041S

S22.042A

S22.042B

S22.042S

S22.048A

S22.048B

S22.048S

S22.049A

S22.049B

S22.049S

S22.050A

S22.050B

S22.050S

S22.051A

S22.051B

S22.051S

S22.052A