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.
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.
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IONM performed for more than one procedure at a time is considered not medically necessary.
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
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.
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Q07.02
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Q07.03
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Q25.72
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Q28.2
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Q28.3
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Q77.8
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|
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Q85.00
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Q85.01
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Q85.02
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Q85.03
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S14.149S
|
|
S14.151A
|
S14.151S
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S14.152A
|
S14.152S
|
S14.153A
|
S14.153S
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S14.154A
|
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S14.154S
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S14.155A
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S14.155S
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S14.156A
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S14.156S
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S14.157A
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S14.157S
|
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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
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|
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
|
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S22.041S
|
S22.042A
|
S22.042B
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S22.042S
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S22.048A
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S22.048B
|
S22.048S
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S22.049A
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S22.049B
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S22.049S
|
S22.050A
|
S22.050B
|
S22.050S
|
S22.051A
|
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S22.051B
|
S22.051S
|
S22.052A
|
S22.052B
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S22.052S
|
S22.058A
|
S22.058B
|
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S22.058S
|
S22.059A
|
S22.059B
|
S22.059S
|
S22.060A
|
S22.060B
|
S22.060S
|
|
S22.061A
|
S22.061B
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S22.061S
|
S22.062A
|
S22.062B
|
S22.062S
|
S22.068A
|
|
S22.068B
|
S22.068S
|
S22.069A
|
S22.069B
|
S22.069S
|
S22.070A
|
S22.070B
|
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S22.070S
|
S22.071A
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S22.071B
|
S22.071S
|
S22.072A
|
S22.072B
|
S22.072S
|
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S22.078A
|
S22.078B
|
S22.078S
|
S22.079A
|
S22.079B
|
S22.079S
|
S22.080A
|
|
S22.080B
|
S22.080S
|
S22.081A
|
S22.081B
|
S22.081S
|
S22.082A
|
S22.082B
|
|
S22.082S
|
S22.088A
|
S22.088B
|
S22.088S
|
S22.089A
|
S22.089B
|
S22.089S
|
|
S24.0XXA
|
S24.0XXS
|
S24.101A
|
S24.101S
|
S24.102A
|
S24.102S
|
S24.103A
|
|
S24.103S
|
S24.104A
|
S24.104S
|
S24.109A
|
S24.109S
|
S24.111A
|
S24.111S
|
|
S24.112A
|
S24.112S
|
S24.113A
|
S24.113S
|
S24.114A
|
S24.114S
|
S24.119A
|
|
S24.119S
|
S24.131A
|
S24.131S
|
S24.132A
|
S24.132S
|
S24.133A
|
S24.133S
|
|
S24.134A
|
S24.134S
|
S24.139A
|
S24.139S
|
S24.141A
|
S24.141S
|
S24.142A
|
|
S24.142S
|
S24.143A
|
S24.143S
|
S24.144A
|
S24.144S
|
S24.149A
|
S24.149S
|
|
S24.151A
|
S24.151S
|
S24.152A
|
S24.152S
|
S24.153A
|
S24.153S
|
S24.154A
|
|
S24.154S
|
S24.159A
|
S24.159S
|
S24.2XXA
|
S24.2XXS
|
S32.000A
|
S32.000B
|
|
S32.000S
|
S32.001A
|
S32.001B
|
S32.001S
|
S32.002A
|
S32.002B
|
S32.002S
|
|
S32.008A
|
S32.008B
|
S32.008S
|
S32.009A
|
S32.009B
|
S32.009S
|
S32.010A
|
|
S32.010B
|
S32.010S
|
S32.011A
|
S32.011B
|
S32.011S
|
S32.012A
|
S32.012B
|
|
S32.012S
|
S32.018A
|
S32.018B
|
S32.018S
|
S32.019A
|
S32.019B
|
S32.019S
|
|
S32.020A
|
S32.020B
|
S32.020S
|
S32.021A
|
S32.021B
|
S32.021S
|
S32.022A
|
|
S32.022B
|
S32.022S
|
S32.028A
|
S32.028B
|
S32.028S
|
S32.029A
|
S32.029B
|
|
S32.029S
|
S32.030A
|
S32.030B
|
S32.030S
|
S32.031A
|
S32.031B
|
S32.031S
|
|
S32.032A
|
S32.032B
|
S32.032S
|
S32.038A
|
S32.038B
|
S32.038S
|
S32.039A
|
|
S32.039B
|
S32.039S
|
S32.040A
|
S32.040B
|
S32.040S
|
S32.041A
|
S32.041B
|
|
S32.041S
|
S32.042A
|
S32.042B
|
S32.042S
|
S32.048A
|
S32.048B
|
S32.048S
|
|
S32.049A
|
S32.049B
|
S32.049S
|
S32.050A
|
S32.050B
|
S32.050S
|
S32.051A
|
|
S32.051B
|
S32.051S
|
S32.052A
|
S32.052B
|
S32.052S
|
S32.058A
|
S32.058B
|
|
S32.058S
|
S32.059A
|
S32.059B
|
S32.059S
|
S32.10XA
|
S32.10XB
|
S32.10XS
|
|
S32.110A
|
S32.110B
|
S32.110S
|
S32.111A
|
S32.111B
|
S32.111S
|
S32.112A
|
|
S32.112B
|
S32.112S
|
S32.119A
|
S32.119B
|
S32.119S
|
S32.120A
|
S32.120B
|
|
S32.120S
|
S32.121A
|
S32.121B
|
S32.121S
|
S32.122A
|
S32.122B
|
S32.122S
|
|
S32.129A
|
S32.129B
|
S32.129S
|
S32.130A
|
S32.130B
|
S32.130S
|
S32.131A
|
|
S32.131B
|
S32.131S
|
S32.132A
|
S32.132B
|
S32.132S
|
S32.139A
|
S32.139B
|
|
S32.139S
|
S32.14XA
|
S32.14XB
|
S32.14XS
|
S32.15XA
|
S32.15XB
|
S32.15XS
|
|
S32.16XA
|
S32.16XB
|
S32.16XS
|
S32.17XA
|
S32.17XB
|
S32.17XS
|
S32.19XA
|
|
S32.19XB
|
S32.19XS
|
S32.2XXA
|
S32.2XXB
|
S32.2XXS
|
S34.01XA
|
S34.01XS
|
|
S34.02XA
|
S34.02XS
|
S34.101A
|
S34.101S
|
S34.102A
|
S34.102S
|
S34.103A
|
|
S34.103S
|
S34.104A
|
S34.104S
|
S34.105A
|
S34.105S
|
S34.109A
|
S34.109S
|
|
S34.111A
|
S34.111S
|
S34.112A
|
S34.112S
|
S34.113A
|
S34.113S
|
S34.114A
|
|
S34.114S
|
S34.115A
|
S34.115S
|
S34.119A
|
S34.119S
|
S34.121A
|
S34.121S
|
|
S34.122A
|
S34.122S
|
S34.123A
|
S34.123S
|
S34.124A
|
S34.124S
|
S34.125A
|
|
S34.125S
|
S34.129A
|
S34.129S
|
S34.131A
|
S34.131S
|
S34.132A
|
S34.132S
|
|
S34.139A
|
S34.139S
|
S34.21XA
|
S34.21XS
|
S34.22XA
|
S34.22XS
|
S34.3XXA
|
|
S34.3XXS
|
S34.4XXA
|
S34.4XXS
|
S44.00XA
|
S44.00XS
|
S44.01XA
|
S44.01XS
|
|
S44.02XA
|
S44.02XS
|
S44.10XA
|
S44.10XS
|
S44.11XA
|
S44.11XS
|
S44.12XA
|
|
S44.12XS
|
S44.20XA
|
S44.20XS
|
S44.21XA
|
S44.21XS
|
S44.22XA
|
S44.22XS
|
|
S44.30XA
|
S44.30XS
|
S44.31XA
|
S44.31XS
|
S44.32XA
|
S44.32XS
|
S44.40XA
|
|
S44.40XS
|
S44.41XA
|
S44.41XS
|
S44.42XA
|
S44.42XS
|
S44.50XA
|
S44.50XS
|
|
S44.51XA
|
S44.51XS
|
S44.52XA
|
S44.52XS
|
S44.8X1A
|
S44.8X1S
|
S44.8X2A
|
|
S44.8X2S
|
S44.8X9A
|
S44.8X9S
|
S44.90XA
|
S44.90XS
|
S44.91XA
|
S44.91XS
|
|
S44.92XA
|
S44.92XS
|
S54.00XA
|
S54.00XS
|
S54.01XA
|
S54.01XS
|
S54.02XA
|
|
S54.02XS
|
S54.10XA
|
S54.10XS
|
S54.11XA
|
S54.11XS
|
S54.12XA
|
S54.12XS
|
|
S54.20XA
|
S54.20XS
|
S54.21XA
|
S54.21XS
|
S54.22XA
|
S54.22XS
|
S54.30XA
|
|
S54.30XS
|
S54.31XA
|
S54.31XS
|
S54.32XA
|
S54.32XS
|
S54.8X1A
|
S54.8X1S
|
|
S54.8X2A
|
S54.8X2S
|
S54.8X9A
|
S54.8X9S
|
S54.90XA
|
S54.91XA
|
S54.92XA
|
|
S64.00XA
|
S64.00XS
|
S64.01XA
|
S64.01XS
|
S64.02XA
|
S64.02XS
|
S64.10XA
|
|
S64.10XS
|
S64.11XA
|
S64.11XS
|
S64.12XA
|
S64.12XS
|
S64.20XA
|
S64.20XS
|
|
S64.21XA
|
S64.21XS
|
S64.22XA
|
S64.22XS
|
S64.30XA
|
S64.30XS
|
S64.31XA
|
|
S64.31XS
|
S64.32XA
|
S64.32XS
|
S64.40XA
|
S64.40XS
|
S64.490A
|
S64.490S
|
|
S64.491A
|
S64.491S
|
S64.492A
|
S64.492S
|
S64.493A
|
S64.493S
|
S64.494A
|
|
S64.494S
|
S64.495A
|
S64.495S
|
S64.496A
|
S64.496S
|
S64.497A
|
S64.497S
|
|
S64.498A
|
S64.498S
|
S64.8X1A
|
S64.8X1S
|
S64.8X2A
|
S64.8X2S
|
S64.8X9A
|
|
S64.8X9S
|
S64.90XA
|
S64.90XS
|
S64.91XA
|
S64.91XS
|
S64.92XA
|
S64.92XS
|
|
S74.00XA
|
S74.00XS
|
S74.01XA
|
S74.01XS
|
S74.02XA
|
S74.02XS
|
S74.10XA
|
|
S74.10XS
|
S74.11XA
|
S74.11XS
|
S74.12XA
|
S74.12XS
|
S74.20XA
|
S74.20XS
|
|
S74.21XA
|
S74.21XS
|
S74.22XA
|
S74.22XS
|
S74.8X1A
|
S74.8X1S
|
S74.8X2A
|
|
S74.8X2S
|
S74.8X9A
|
S74.8X9S
|
S74.90XA
|
S74.90XS
|
S74.91XA
|
S74.91XS
|
|
S74.92XA
|
S74.92XS
|
S84.00XA
|
S84.00XS
|
S84.01XA
|
S84.01XS
|
S84.02XA
|
|
S84.02XS
|
S84.10XA
|
S84.10XS
|
S84.11XA
|
S84.11XS
|
S84.12XA
|
S84.12XS
|
|
S84.20XA
|
S84.20XS
|
S84.21XA
|
S84.21XS
|
S84.22XA
|
S84.22XS
|
S84.801A
|
|
S84.801S
|
S84.802A
|
S84.802S
|
S84.809A
|
S84.809S
|
S84.90XA
|
S84.90XS
|
|
S84.91XA
|
S84.91XS
|
S84.92XA
|
S84.92XS
|
S94.00XA
|
S94.00XS
|
S94.01XA
|
|
S94.01XS
|
S94.02XA
|
S94.02XS
|
S94.10XA
|
S94.10XS
|
S94.11XA
|
S94.11XS
|
|
S94.12XA
|
S94.12XS
|
S94.20XA
|
S94.20XS
|
S94.21XA
|
S94.21XS
|
S94.22XA
|
|
S94.22XS
|
S94.30XA
|
S94.30XS
|
S94.31XA
|
S94.31XS
|
S94.32XA
|
S94.32XS
|
|
S94.8X1A
|
S94.8X1S
|
S94.8X2A
|
S94.8X2S
|
S94.8X9A
|
S94.8X9S
|
S94.90XA
|
|
S94.90XS
|
S94.91XA
|
S94.91XS
|
S94.92XA
|
S94.92XS
|
T68.XXXA
|
T68.XXXD
|
|
T68.XXXS
|
T84.216A
|
T84.216D
|
T84.216S
|
T84.226A
|
T84.226D
|
T84.226S
|
|
T84.296A
|
T84.296D
|
T84.296S
|
T84.310A
|
T84.310D
|
T84.310S
|
T84.318A
|
|
T84.318D
|
T84.318S
|
T84.320A
|
T84.320D
|
T84.320S
|
T84.328A
|
T84.328D
|
|
T84.328S
|
T84.390A
|
T84.390D
|
T84.390S
|
T84.398A
|
T84.398D
|
T84.398S
|
|
Z45.41
|
Z45.42
|
Z45.49
|
|
|
|
|
|
Place of Service: Inpatient/Outpatient
Experimental/Investigational (E/I) services are not covered regardless of place of service.
IONM is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting. is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
The policy position applies to all commercial lines of business
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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
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, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295
, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
