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
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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92650 |
92651 |
92652 |
92653 |
95829 |
95860 |
95861 |
95863 |
95864 |
95867 |
95868 |
95907 |
95908 |
95910 |
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95955 |
G0453 |
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IONM performed for more than one procedure at a time is considered not medically necessary.
95941 |
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IONM of the recurrent laryngeal nerve may be considered medically necessary in individuals undergoing:
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 |
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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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