Intraoperative Neurological Monitoring - Paramount Health Care

[Pages:5]Intraoperative Neurological Monitoring

Policy Number: PG0326 Last Review: 07/13/2021

HMO & PPO MARKETPLACE MEDICARE ? ELITE, MAP & PROMEDICA

IMPORTANT | For Paramount Advantage Only: Paramount medical policies only apply to Paramount Advantage Medicaid claims with dates of service before Feb. 1, 2023. Please contact Anthem, for Medicaid claims with dates of service on or after Feb. 1, 2023.

GUIDELINES ? This policy does not certify benefits or authorization of benefits, which is designated by each individual

policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. ? Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. ? This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits.

SCOPE X Professional _ Facility

DESCRIPTION Intraoperative neurological monitoring (IOM) is the recording of nerve signals and brainwaves during surgery to monitor and thereby reduce the risk of significant nerve damage. Most often used in surgeries that pose risk to a specific part of the nervous system, such as procedures of the brain, peripheral nerves, spine, vasculature (e.g., carotid endarterectomies and thoracic abdominal aortic aneurysms) and some ear/nose/throat (ENT) procedures. The principal goal of intraoperative monitoring is the identification of nervous system impairment in the hope that prompt intervention will prevent permanent deficits. Intraoperative neurological monitoring may utilize brainstem auditory evoked potentials (BAEP), electroencephalogram (EEG), electromyogram (EMG), motor evoked potentials (MEP), somatosensory evoked potentials (SEP or SSEP), visual evoked potentials (VEP), depending on the type of surgery being performed.

The technical components of this testing are part of the facility fee, just as are the technical components of radiological testing. When continuous intraoperative neurophysiological monitoring is provided for the indications noted below by a physician other than the surgical team, and that physician is in personal attendance in the operating room, for the entire duration of monitoring, that component may be separately billed with the appropriate code.

POLICY Paramount Commercial Plans, Medicare Advantage Plans and Paramount Medicaid Advantage

Intraoperative neurological monitoring does not require prior authorization. Intraoperative monitoring is considered reimbursable as a separate service only when a licensed physician, other than the operating surgeon or anesthesiologist, performs the monitoring while in attendance in the operating room throughout the procedure.

Paramount Medicaid Advantage

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Procedure G0453 is non-covered for Advantage

Medicare Advantage Plans Procedure 95941 is non-covered for Elite/ProMedica Medicare Plan

COVERAGE CRITERIA Paramount Commercial Plans, Medicare Advantage Plans and Paramount Medicaid Advantage Paramount members may be eligible for intraoperative neurological monitoring (BAEP, EEG, EMG, MEP, SSEP) during spinal, neurologic, cranial, or vascular procedures that may compromise neurologic function when ALL of the following criteria are met:

? Monitoring is requested by the operating surgeon, the technical/surgical assistant or the anesthesiologist rendering the anesthesia

? Monitoring is performed and interpreted by either a licensed physician trained in clinical neurophysiology (e.g., neurologist, physiatrist) or by a trained technologist who is practicing within the scope of his/her license/certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology

? The professional component of intraoperative neurophysiological monitoring may be considered reimbursable as a separate service only when a licensed physician trained in clinical neurophysiology (e.g., neurologist, physiatrist), who is not a member of the surgical team performs the dedicated/exclusive monitoring while in attendance in the operating room (or on-site) throughout the pertinent portions of the procedure

? Monitoring should not be reported by the physician performing the operative or anesthesia procedure since it is included in the global package. However, when performed by a different physician during the procedure, it is separately reportable by the second physician.

? Monitoring period includes only intraoperative time. This time, however, may be cumulative, and does not have to be continuous, i.e., one-half hour of continuous attendance followed by another one-half hour of continuous attendance later in the procedure will constitute one hour of monitoring

The technical components of these services are considered to be included in the facility fee, just as the technical components of intraoperative radiological testing are.

Examples of indications for which intraoperative monitoring MAY be utilized include, but are not limited to: ? Anterior approach for cervical procedures ( e.g., carotid artery endarterectomy) ? Aortic arch and the branch vessels surgical procedures ? Brachial plexus surgery ? Bronchial artery arteriovenous malformations or tumor embolization ? Correction of cerebral vascular aneurysms ? Correction of intracranial or spinal arteriovenous malformations ? Correction of scoliosis ? Deep brain stimulation ? Descending aortic open surgical and endovascular procedures (eg, thoracic or thoracoabdominal aortic aneurysm repair ? High risk thyroid surgery (e.g., malignancy, reoperation, retrosternal approach or toxic goiter) ? Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks ? Meniere disease surgical procedures (eg, endolymphatic shunt, vestibular neurectomy) ? Multi-level cervical fusions with instrumentation ? Nontraumatic spinal cord lesions (e.g., cervical spondylosis) ? Peripheral nerve neuromas of the brachial plexus with risk to major sensory or motor nerves ? Protection of cranial nerves associated with any of the following o Tumors that affect optic, trigeminal, facial, or auditory nerves o Cavernous sinus tumors o Microvascular decompression of cranial nerves o Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum o Oval or round window graft

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? Removal of spinal cord tumors ? Removal of tumors that affect the cranial nerves ? Spinal cord trauma ? Spinal procedures that pose a potential risk of significant damage to an essential central nervous system

structure ? Tethered cord release ? Traumatic injury to the brain or spinal cord

Intraoperative neurophysiologic monitoring during thyroid surgery is considered reasonable and necessary if the monitoring service adheres to the essential standards described above, and the surgical procedure involves the high-risk total removal of a complete lobe of the thyroid, removal of the entire gland, or involves re-entry (reoperation) to a prior surgical field where scar tissue obscures the visual path of the recurrent laryngeal nerve. The surgeries described here are most appropriately reported as a total removal of thyroid lobe on one side of the neck, removal of thyroid, removal of thyroid and surrounding lymph nodes or removal of remaining thyroid tissue. The contractor reserves the right to remove coverage for monitoring during thyroid surgery if the literature ultimately does not support this monitoring.

Due to the nature of these services and the potential for significant morbidity, in procedures requiring intraoperative monitoring, these services are considered reasonable and necessary only when performed in the inpatient and outpatient hospital settings or Ambulatory Surgical Center. Please note, the outpatient settings are only considered reasonable and necessary for intraoperative monitoring of procedures that are not designated as inpatient-only procedures.

For coverage of remote monitoring, undivided attention to a unique patient will be required during surgeries covered for this procedure and the neurophysiologist must have immediate physical or real-time communication with the operating room. They must have the ability to watch the tracings as they are obtained in real-time in the operating room as well as the baseline electrophysiological test and the monitoring tracings from earlier in the case. Monitoring may be performed from a remote site, as long as a trained technician will be in continuous attendance in the

operating room, with either the physical or the electronic capacity for real-time communication with the supervising physician (MD/DO). Technical criteria (mandatory) include that at least eight recording channels be available (16 if EEG is monitored) for all intraoperative neurophysiological monitoring. The remotely supervising physician must watch the tracings as they are obtained in real-time in the operating room, as well as the baseline electrophysiological test and the monitoring tracings from earlier in the case.

Intraoperative EMG monitoring used to aid in pedicle screw placement is considered integral to the primary intraoperative neurological monitoring and not separately reimbursable.

Neuromuscular blockade testing (eg, Train of Four testing) used to monitor the depth of pharmacologic muscle relaxation is considered integral to the primary intraoperative neurological monitoring and not separately reimbursable.

Examples of indications for which intraoperative monitoring MAY NOT be utilized include, but are not limited to: ? Intraoperative neurological monitoring should not be performed when monitoring is not likely to alter surgical outcomes ? Routine cervical/lumbar/thoracic fusion ? Routine cervical/lumbar/thoracic laminectomy o Decompressive laminectomy for stenosis o Decompression or discectomy for disc herniation ? Cardiac surgery

Intraoperative visual-evoked potentials (VEP) monitoring for any indications is considered experimental/investigational as it is not identified as widely used and generally accepted because the safety and /or effectiveness of this service cannot be established by the available peer-reviewed literature (95930 ? not covered if used to report intraoperative VEP monitoring).

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Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental/investigational and therefore, noncovered because the safety and/ or effectiveness of this service cannot be established by the available peer-reviewed literature.

Intraoperative SEMG monitoring (eg, EPAD 2.0) is considered experimental/investigational as it is not identified as widely used and generally accepted.

CODING/BILLING INFORMATION The inclusion or exclusion of a code in this section does not necessarily indicate coverage. Codes referenced in this clinical policy are for informational purposes only. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

CPT CODES 92585 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous

system; comprehensive (Deleted code 1/1/2021) 92586 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous

system; limited (Deleted code 1/1/2021) 92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated

analysis (New Code 1/1/2021) 92651 Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation

and report (New Code 1/1/2021) 92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and

report (New Code 1/1/2021) 92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report (New Code 1/1/2021) 95822 Electroencephalogram (EEG); recording in coma or sleep only) 95829 Electrocorticogram at surgery (separate procedure) 95860 Needle electromyography; 1 extremity with or without related paraspinal areas 95861 Needle electromyography; 2 extremities with or without related paraspinal areas 95863 Needle electromyography; 3 extremities with or without related paraspinal areas 95864 Needle electromyography; 4 extremities with or without related paraspinal areas 95865 Needle electromyography; larynx 95866 Needle electromyography; hemidiaphragm 95867 Needle electromyography; cranial nerve supplied muscle(s), unilateral 95868 Needle electromyography; cranial nerve supplied muscles, bilateral 95869 Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12) 95870 Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles

(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 95907 Nerve conduction studies; 1-2 studies 95908 Nerve conduction studies; 3-4 studies 95909 Nerve conduction studies; 5-6 studies 95910 Nerve conduction studies; 7-8 studies 95911 Nerve conduction studies; 9-10 studies 95912 Nerve conduction studies; 11-12 studies 95913 Nerve conduction studies; 13 or more studies 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin

sites, recording from the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin

sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin

sites, recording from the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 95930 Visual evoked potential (VEP) testing central nervous system, checkerboard or flash 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method

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95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs

95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 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) 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) Note: CPT code 95941 is invalid for Medicare, thus Medicare Advantage Plans 95955 Electroencephalogram (EEG) during non-intracranial surgery (eg, carotid surgery) HCPCS CODE G0453 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)

REVISION HISTORY EXPLANATION

ORIGINAL EFFECTIVE DATE: 11/10/2015

Date Explanation & Changes

11/10/15

? Policy created to reflect most current clinical evidence per Medical Policy Steering Committee

12/21/2020

? Medical policy placed on the new Paramount Medical Policy Format

? Documented that procedures 92585 and 92586 are Deleted Codes as of 1/1/2021

07/13/2021

? Added new 2021 procedures 92650-92653

? Updated coverage and noncoverage criteria to most recent industry standards

02/22/2023

? Medical Policy updated to reflect Medicaid coverage to Anthem as of 02/01/2023

Paramount reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to .

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and

services

Ohio Department of Medicaid

American Medical Association, Current Procedural Terminology (CPT?) and associated publications and services

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets

U.S. Preventive Services Task Force, Industry Standard Review

Hayes, Inc.

Industry Standard Review

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