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DESCRIPTIONIntra-operative neurophysiologic monitoring describes a variety of procedures that have been used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic and vascular surgeries. The principal goal of intra-operative monitoring is the identification of nervous system impairment in the hope that prompt intervention will prevent permanent deficits. Correctable factors at surgery include circulatory disturbance, excess compression from retraction, bony structures or hematomas, or mechanical stretching. The various different methodologies of monitoring are described below:
Sensory-evoked potential describes the responses of the sensory pathways to sensory or electrical stimuli. Intra-operative monitoring of sensory-evoked potentials is used to assess the functional integrity of Central Nervous System (CNS) pathways during operations that put the spinal cord or brain at risk for significant ischemia or traumatic injury. The basic principles of sensory-evoked potential monitoring involves identification of a neurological region at risk, selection and stimulation of a nerve that carries a signal through the at risk region, and recording and interpretation of the signal at certain standardized points along the pathway. Monitoring of sensory-evoked potentials is commonly used during the following procedures: carotid endarterectomy, brain surgery involving vasculature, surgery with distraction compression or ischemia of the spinal cord and brainstem, and acoustic neuroma surgery. Sensory-evoked potentials can be further broken down into the following categories according to the type of simulation used:
EMG (Electromyogram) Monitoring and Nerve Conduction Velocity Measurements
Motor -Evoked Potential Monitoring
This type of monitoring involves stimulation to the motor cortex using a magnetic coil placed over the head. The electromagnetic energy induces an electrical current within the brain which in turn can stimulate the motor neurons. While there is ongoing research interest in the use of motor-evoked potentials to assess the integrity of the corticospinal tracts (which are not assessed using sensory-evoked potentials), this technique has not yet received U.S. Food and Drug Administration (FDA) approval.
EEG (Electroencephalogram) Monitoring
Spontaneous EEG monitoring can also be recorded during surgery and can be subdivided as follows:
POLICYIntraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG, and electrocorticography (ECoG), may be considered medically necessary during spinal, intracranial, or vascular procedures.
Intra-operative monitoring of visual-evoked potentials is considered investigational.
Due to the lack of FDA approval, intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered investigational.
Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary.
Intraoperative monitoring typically is done in the operating room (OR) by a technician, with a physician as a remote backup. In some ORs’ there is a central physician monitoring room, where a physician may simultaneously monitor several cases.
Intraoperative monitoring is considered reimbursable as a separate service only when a licensed physician, other than the operating surgeon, performs the monitoring while in attendance in the operating room throughout the procedure.
POLICY EXCEPTIONSFederal Employee Program (FEP) Members Only: Effective 03/10/11, intraoperative monitoring is considered reimbursable as a separate service only when a licensed healthcare practitioner, other than the operating surgeon, interprets the monitoring. The monitoring is performed by a healthcare practitioner or technician who is in attendance in the operating room throughout the procedure.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/2002: Approved by Medical Policy Advisory Committee (MPAC)
3/2004: Code Reference section completed
2/6/2007: Policy reviewed, no changes
9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy, ICD9 Procedure code 00.94 added for 10/01/2007 revisions.
10/02/2009: Coding Section updated to include coding rule information specific to CPT-4 code 95920. CPT-4 codes 95961 and 95962 removed from Covered Codes Table. ICD-9 Procedure code 04.19 removed from Covered Codes Table. ICD-9 Diagnosis codes 433.10, 433.11, 737.30- 737.34, 737.39, 737.43, and 754.2 removed from Covered Codes Table. Added verbiage, "* Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section." to the Covered Codes Section.
06/21/2011: Policy statement revised to state that motor-evoked potentials using transcranial electrical stimulation may be considered medically necessary, and motor-evoked potential using transcranial magnetic stimulation is investigational. The Policy Exceptions section was updated to add the following verbiage: "Federal Employee Program (FEP) Members Only: Effective 03/10/11, intraoperative monitoring is considered reimbursable as a separate service only when a licensed healthcare practitioner, other than the operating surgeon, interprets the monitoring. The monitoring is performed by a healthcare practitioner or technician who is in attendance in the operating room throughout the procedure."
12/21/2012: Added the following new 2013 CPT codes to the Code Reference section: 95940, 95941, and G0453.
Blue Cross Blue Shield Association policy # 7.01.58
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
This is not an all-inclusive list of non-covered procedure codes.
The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.