Latest Review Date: April 2024

Category:  Medical                                                                

POLICY:

Effective for dates of service on and after May 15, 2022:

Continuous intraoperative neurophysiologic monitoring (IONM) may be considered medically necessary during spinal, intracranial, vascular, or other specific procedures* listed below when ALL of the following criteria are met:

• IONM is performed by either a licensed physician trained in clinical neurophysiology (other than the operating surgeon or anesthesiologist) or a trained technologist who is practicing within the scope of his/her state license /certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology, and is not the operating surgeon or anesthesiologist.

AND

• IONM is conducted and interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon or anesthesiologist, who is either physically in attendance in the operating suite or present by means of a real-time remote mechanism for all electro-neurodiagnostic (END) monitoring situations and is continuously communicating and available to interpret the recording and advise the surgeon.

AND

• IONM monitoring must be conducted and interpreted in real-time (either on-site, or at a remote location) and continuously communicated to the surgical team. 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 monitoring physician.

* Individual criteria for specific procedures for Intraoperative neurophysiologic monitoring:

• Recurrent laryngeal nerve may be considered medically necessary in individuals undergoing high-risk thyroid or parathyroid surgery, including:
  • Total thyroidectomy
  • Repeat thyroid or parathyroid surgery
  • Surgery for cancer
  • Thyrotoxicosis
  • Retrosternal or giant goiter
  • Thyroiditis
• Anterior cervical spine surgery associated with any of the following increased risk situations:
  • 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
  • Multilevel anterior cervical discectomy and fusion
  • Pre-existing recurrent laryngeal nerve pathology, when there is residual function of the recurrent laryngeal nerve.

Intraoperative neurophysiologic monitoring of the recurrent laryngeal nerve during anterior cervical spine surgery not meeting the criteria above or during esophageal surgeries is considered investigational.

Intraoperative monitoring of visual-evoked potentials is considered investigational.

Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered investigational.

Intraoperative electromyography (EMG) and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary.

Intraoperative neurophysiologic monitoring includes:

• Somatosensory-evoked potentials.
• Motor-evoked potentials using transcranial electrical stimulation.
• Brainstem auditory-evoked potentials.
• EMG of cranial nerves.
• EEG
• Electrocorticography (ECoG)

Effective for dates of service prior to May 15, 2022:

Intraoperative neurophysiologic 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, vascular procedures or follows individual criteria for specific procedures* listed below when all of the following criteria are met:

1. There is clinical data in the medical record to support the medical necessity of ordering the test.  The data could include radiological, neurological, consultative notes, or physical exam documentation; and
2. A licensed physician other than the operating surgeon or performing anesthesiologist must monitor the procedure and the monitoring physician must be on the premises and available to be in the operating room;

* Individual criteria for specific procedures for Intraoperative neurophysiologic monitoring:

• Recurrent laryngeal nerve may be considered medically necessary in patients undergoing high-risk thyroid or parathyroid surgery, including:
  • Total thyroidectomy
  • Repeat thyroid or parathyroid surgery
  • Surgery for cancer
  • Thyrotoxicosis
  • Retrosternal or giant goiter
  • Thyroiditis
• Anterior cervical spine surgery associated with any of the following increased risk situations:
  • 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
  • Multilevel anterior cervical discectomy and fusion
  • Pre-existing recurrent laryngeal nerve pathology, when there is residual function of the recurrent laryngeal nerve.

Intraoperative neurophysiologic monitoring of the recurrent laryngeal nerve during anterior cervical spine surgery not meeting the criteria above or during esophageal surgeries is considered investigational.

Intraoperative monitoring of visual-evoked potentials is considered investigational.

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.

Note: These policy statements refer only to use of these techniques as part of intraoperative monitoring. Other clinical applications of these techniques, such as visual-evoked potentials and EMG, are not considered in this policy.

DESCRIPTION OF PROCEDURE OR SERVICE:

Intraoperative neurophysiologic monitoring (IONM) describes a variety of procedures used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries. It involves the detection of electrical signals produced by the nervous system in response to sensory or electrical stimuli to provide information about the functional integrity of neuronal structures. This evidence review does not address established neurophysiologic monitoring (i.e., somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography of cranial nerves, electroencephalography, electrocorticography), during spinal, intracranial, or vascular procedures.

Intraoperative Neurophysiologic Monitoring

The principal goal of intraoperative monitoring is the identification of nervous system impairment in the assumption that prompt intervention will prevent permanent deficits. Correctable factors at surgery include circulatory disturbance, excess compression from retraction, bony structures, hematomas, or mechanical stretching. The technology is continuously evolving with refinements in equipment and analytic techniques including recording, with several individuals are monitored under the supervision of a physician who is outside the operating room. The different methodologies of monitoring are described below.

Sensory-Evoked Potentials

Sensory-evoked potential describes the responses of the sensory pathways to sensory or electrical stimuli. Intraoperative 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 involve 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 in 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 categorized type of stimulation used, as follows.

Somatosensory-evoked potentials (SSEPs)

Somatosensory-evoked potentials (SSEPs) are cortical responses elicited by peripheral nerve stimulations. Peripheral nerves, such as the median, ulnar, or tibial nerve are typically stimulated, but in some situations, the spinal cord may be stimulated directly. Recording is done either cortically or at the level of the spinal cord above the surgical procedure. Intra-operative monitoring of SSEPs is most commonly used during orthopedic or neurologic surgery to prompt intervention to reduce surgically induced morbidity and/or to monitor the level of anesthesia. One of the most common indications for SSEP monitoring is in individuals undergoing corrective surgery for scoliosis. In this setting, SSEP monitors the status of the posterior column pathways, and thus does not reflect ischemia in the anterior (motor) pathways. Several different techniques are commonly used, including stimulation of a relevant peripheral nerve with monitoring from the scalp, from interspinous ligament needle electrodes, or from catheter electrodes in the epidural space.

Brainstem Auditory-Evoked Potentials (BAEPs)

Brainstem auditory-evoked potentials (BAEPs) are generated in response to auditory clicks and can define the functional status of the auditory nerve. Surgical resection of a cerebellopontine angle tumor, such as an acoustic neuroma, places the auditory nerves at risk, and BAEPs have been extensively used to monitor auditory function during these procedures.

Visual-Evoked Potentials (VEPs)

Visual-evoked potentials (VEPs) are used to track visual signals from the retina to the occipital cortex light flashes. VEP monitoring has been used for surgery on lesions near the optic chiasm. However, VEPs are very difficult to interpret due to their sensitivity to anesthesia, temperature, and blood pressure.

Motor-Evoked Potentials

Motor-evoked potentials are recorded from muscles following direct or transcranial electrical stimulation of motor cortex or pulsed magnetic stimulation provided using  a coil placed over the head. Peripheral motor responses (muscle activity) are recorded by electrodes placed on the skin at prescribed points along the motor pathways. Motor-evoked potentials, especially when induced by magnetic stimulation, can be affected by anesthesia. The Digitimer electrical cortical stimulator received U.S. Food and Drug Administration (FDA) premarket approval in 2002. Devices for transcranial magnetic stimulation have not been approved by the FDA for this use. 

Multimodal intraoperative neurophysiologic monitoring, in which more than 1 technique is used, most commonly with somatosensory-evoked potentials and motor-evoked potentials, has also been described.

Electromyogram (EMG) Monitoring and Nerve Conduction Velocity Measurements

Electromyogram (EMG) monitoring and nerve conduction velocity measurements can be performed in the operating room and may be used to assess the status of the cranial or peripheral nerves (e.g., to identify the extent of nerve damage prior to nerve grafting or during resection of tumors). For procedures with a risk of vocal cord paralysis due to damage to the recurrent laryngeal nerve (i.e., during carotid artery, thyroid, parathyroid, goiter, or anterior cervical spine procedures), monitoring of the vocal cords or vocal cord muscles has been performed. These techniques may also be used during procedures proximal to the nerve roots and around peripheral nerves to assess the presence of excessive traction or other impairment. Surgery in the region of cranial nerves can be monitored by electrically stimulating the proximal (brain) end of the nerve and recording via EMG in the facial or neck muscles. Thus, monitoring is done in the direction opposite that of sensory-evoked potentials but the purpose is similar, to verify that the neural pathway is intact.

EEG (Electroencephalogram) Monitoring

Spontaneous electroencephalogram (EEG) monitoring can also be recorded during surgery and can be subdivided as follows:

• EEG monitoring has been widely used to monitor cerebral ischemia secondary to carotid cross-clamping during a carotid endarterectomy. EEG monitoring may identify those individuals who would benefit from the use of a vascular shunt during the procedure to restore adequate cerebral perfusion. Conversely, shunts, which have an associated risk of iatrogenic complications, may be avoided in those individuals with normal EEG activity. Carotid endarterectomy may be done with the individual under local anesthesia so that monitoring of cortical function can be directly assessed.
• Electrocorticography (ECoG) is the recording of the EEG activity directly from a surgically exposed cerebral cortex. ECoG is typically used to define the sensory cortex and to map the critical limits of a surgical resection. ECoG recordings have been most frequently used to identify epileptogenic regions for resection. In these applications, electrocorticography does not constitute monitoring, per se.

Intraoperative neurophysiologic monitoring, including SSEPs and MEPs using transcranial electrical stimulation, BAEPs, EMG of cranial nerves, EEG, and ECoG, has broad acceptance, particularly for spine surgery and open abdominal aorta aneurysm repairs. These indications have long been considered standard of care, as evidenced by numerous society guidelines, including those from the American Academy of Neurology, American Clinical Neurophysiology Society, American Association of Neurological Surgeons, Congress of Neurologic Surgeons, and American Association of Neuromuscular & Electrodiagnostic Medicine. Therefore, this evidence review focuses on monitoring of the recurrent laryngeal nerve during neck and esophageal surgeries and monitoring of peripheral nerves.

KEY POINTS:

The most recent literature update was performed through March 1, 2024.

Summary of Evidence

For individuals who are undergoing thyroid or parathyroid surgery and are at high risk of injury to the recurrent laryngeal nerve who receive intraoperative neurophysiologic monitoring, the evidence includes a large randomized controlled trial (RCT) and systematic reviews. Relevant outcomes are morbid events, functional outcomes, and quality of life. The strongest evidence on neurophysiologic monitoring derives from a RCT of 1000 individuals undergoing thyroid surgery. This RCT found a significant reduction in recurrent laryngeal nerve injury in individuals at high-risk for injury. High-risk in this trial was defined as surgery for cancer, thyrotoxicosis, retrosternal or giant goiter, or thyroiditis. The high-risk category may also include individuals with prior thyroid or parathyroid surgery or total thyroidectomy. A low volume of surgeries might also contribute to a higher risk for recurrent laryngeal nerve injury. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are undergoing anterior cervical spine surgery and are at high-risk of injury to the recurrent laryngeal nerve who receive intraoperative neurophysiologic monitoring, the evidence includes 3 systematic reviews of case series and cohort studies. Relevant outcomes are morbid events, functional outcomes, and quality of life. Two of the 3 analyses compared the risk of nerve injury using intraoperative neurophysiologic monitoring with no intraoperative neurophysiologic monitoring and found no statistically significant difference. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are undergoing esophageal surgery who receive intraoperative neurophysiologic monitoring, the evidence includes a systematic review of mainly nonrandomized comparative studies. Relevant outcomes are morbid events, functional outcomes, and quality of life. The systematic review found less recurrent laryngeal nerve palsy with intraoperative neurophysiologic monitoring but conclusions are limited by the design of the included studies. Current evidence is not sufficiently robust to determine whether neurophysiologic monitoring reduces recurrent laryngeal nerve injury in patients undergoing esophageal surgery. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are undergoing surgery proximal to a peripheral nerve who receive intraoperative neurophysiologic monitoring, the evidence includes case series and a controlled cohort study. Relevant outcomes are morbid events, functional outcomes, and quality of life. Surgical guidance with peripheral intraoperative neurophysiologic monitoring and the predictive ability of monitoring of peripheral nerves have been reported. No prospective comparative studies were identified that assessed whether outcomes are improved with neurophysiologic monitoring. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are undergoing spinal instrumentation requiring screws or distraction who receive intraoperative neurophysiologic monitoring, the evidence consists of systematic reviews of non-randomized studies. Relevant outcomes are morbid events, functional outcomes, and quality of life. The available evidence suggests that intraoperative neurophysiologic monitoring has high sensitivity and specificity for identifying neurologic deficits. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Neurology

In 1990 (updated in 2012, and reaffirmed on April 30, 2014, January 21, 2017, and October 17, 2023), the American Academy of Neurology (AAN) published an assessment of intraoperative neurophysiologic monitoring, with an evidence-based guideline update by the AAN and the American Clinical Neurophysiology Society (ACNS (2012). The 1990 assessment indicated that monitoring requires a team approach with a well-trained physician-neurophysiologist to provide or supervise monitoring. Electroencephalogram (EEG) monitoring is used during carotid endarterectomy or for other similar situations in which cerebral blood flow is at high risk. Electrocorticography from surgically exposed cortex can help to define the optimal limits of surgical resection or identify regions of greatest impairment, while sensory cortex somatosensory-evoked potentials can help to localize the central fissure and motor cortex. Auditory-evoked potentials, along with cranial nerve monitoring can be used during posterior fossa neurosurgical procedures. Spinal cord somatosensory-evoked potentials are frequently used to monitor the spinal cord during orthopedic or neurosurgical procedures around the spinal cord, or cross clamping of the thoracic aorta. Electromyographic monitoring during procedures near the roots and peripheral nerves can be used to warn of excessive traction or other impairment of motor nerves. At the time of the 1990 assessment, motor-evoked potentials were considered investigational by many neurophysiologists. The 2012 update, which was endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), concluded that the available evidence supported intraoperative neurophysiologic monitoring using somatosensory-evoked potentials or motor-evoked potentials when conducted under the supervision of a clinical neurophysiologist experienced with intraoperative neurophysiologic monitoring. Evidence was insufficient to evaluate intraoperative neurophysiologic monitoring when conducted by technicians alone or by an automated device.

In 2012, the AAN published a model policy on principles of coding for intraoperative neurophysiologic monitoring and testing (last amended July 31, 2018). The background section of this document provides the following information on the value of intraoperative neurophysiologic monitoring in averting neural injuries during surgery:

1. "Value of EEG Monitoring in Carotid Surgery. Carotid occlusion, incident to carotid endarterectomies, poses a high-risk for cerebral hemispheric injury. Electroencephalogram (EEG) monitoring is capable of detecting cerebral ischemia, a serious prelude to injury. Studies of continuous monitoring established the ability of electroencephalogram EEG to correctly predict risks of postoperative deficits after a deliberate, but necessary, carotid occlusion as part of the surgical procedure. The surgeon can respond to adverse EEG events by raising blood pressure, implanting a shunt, adjusting a poorly functioning shunt, or performing other interventions.

2. Multicenter Data in Spinal Surgeries. An extensive multicenter study conducted in 1995 demonstrated that [intraoperative neurophysiologic monitoring] using [sensory-evoked potentials] reduced the risk of paraplegia by 60% in spinal surgeries. The incidence of false negative cases, wherein an operative complication occurred without having been detected by the monitoring procedure, was small: 0.06%.

3. Technology Assessment of Monitoring in Spinal Surgeries. A technology assessment by the McGill University Health Center...reviewed 11 studies and concluded that spinal [intraoperative neurophysiologic monitoring] is capable of substantially reducing injury in surgeries that pose a risk to spinal cord integrity. It recommended combined sensory-evoked potentials/motor-evoked potential monitoring, under the presence or constant availability of a monitoring physician, for all cases of spinal surgery for which, there is a risk of spinal cord injury.

4. Value of Combined Motor and Sensory Monitoring. Numerous studies of post-surgical paraparesis and quadriparesis have shown that both sensory-evoked potentials and motor-evoked potential monitoring had predicted adverse outcomes in a timely fashion. The timing of the predictions allowed the surgeons the opportunity to intervene and prevent adverse outcomes. The two different techniques (sensory-evoked potentials and motor-evoked potential) monitor different spinal cord tracts. Sometimes, one of the techniques cannot be used for practical purposes, for anesthetic reasons, or because of preoperative absence of signals in those pathways. Thus, the decision about which of these techniques to use needs to be tailored to the individual patient's circumstances.

5. Protecting the Spinal Cord from Ischemia during Aortic Procedures. Studies have shown that [intraoperative neurophysiologic monitoring] accurately predicts risks for spinal cord ischemia associated with clamping the aorta or ligating segmental spinal arteries. [Intraoperative neurophysiologic monitoring] can assess whether the spinal cord is tolerating the degree of relative ischemia in these procedures. The surgeon can then respond by raising blood pressure, implanting a shunt, re-implanting segmental vessels, draining spinal fluid, or through other interventions...

6. Value of EMG [electromyogram] monitoring. Selective posterior rhizotomy in cerebral palsy significantly reduces spasticity, increases range of motion, and improves functional skills. Electromyography during this procedure can assist in selecting specific dorsal roots to transect. Electromyogram (EMG) can also be used in peripheral nerve procedures that pose a risk of injuries to nerves...

7. Value of Spinal Monitoring using somatosensory-evoked potentials and motor-evoked potentials. According to a recent review of spinal monitoring using somatosensory-evoked potential and motor-evoked potentials by the Therapeutics and Technology Assessment Subcommittee of AAN and ACNS, [intraoperative neurophysiologic monitoring] is established as effective to predict an increased risk of the adverse outcomes of paraparesis, paraplegia, and quadriplegia in spinal surgery (4 Class I and 7 Class II studies). Surgeons and other members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important [intraoperative neurophysiologic monitoring] changes (Level A)."

The AAN model policy also offered guidance on personnel and monitoring standards for intraoperative neurophysiologic monitoring and somatosensory-evoked potential.

American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS)

In 2018, the American Association of Neurological Surgeons and Congress of Neurological Surgeons updated their position statement on IONM during routine spinal surgery. They stated that IONM, especially motor evoked potential, “is a reliable diagnostic tool for assessment of spinal cord integrity during surgery” (Level 1 evidence). Intraoperative motor evoked potentials may also “predict recovery in traumatic cervical spinal cord injury.” However, AANS and CNS found no evidence that such monitoring provides a therapeutic benefit. The statement also recommends that IONM should be used when the operating surgeon believes it is warranted for diagnostic value, such as with “deformity correction, spinal instability, spinal cord compression, intradural spinal cord lesions, and when in proximity to peripheral nerves or roots.” In addition, they recommend spontaneous and evoked electromyography “for minimally invasive lateral retroperitoneal transpsoas approaches to the lumbar spine" and during pedicle screw insertion.

In 2014, the same organizations published guidance on electrophysiological monitoring for lumbar fusion procedures. The authors concluded that there was a lack of high quality studies and that routine intraoperative monitoring during lumbar fusion could not be recommended. Evidence regarding the efficacy of intraoperative monitoring to recover nerve function or affect the outcome of surgery.

American Association of Neuromuscular & Electrodiagnostic Medicine

In 2023, the AANEM updated their position statement on electrodiagnostic medicine. The recommendations indicated that intraoperative sensory-evoked potentials have demonstrated usefulness for monitoring of spinal cord, brainstem, and brain sensory tracts. The AANEM stated that intraoperative somatosensory-evoked potential monitoring is indicated for select spine surgeries in which there is a risk of additional nerve root or spinal cord injury. Indications for somatosensory-evoked potential monitoring may include, but are not limited to, complex, extensive, or lengthy procedures, and when mandated by hospital policy. However, intraoperative somatosensory-evoked potential monitoring may not be indicated for routine lumbar or cervical root decompression.

American Clinical Neurophysiology Society

In 2009, the American Clinical Neurophysiology Society (ACNS) recommended standards for intraoperative neurophysiologic monitoring. Guideline 11A included the following statement:

“The monitoring team should be under the direct supervision of a physician with training and experience in neurophysiologic intraoperative monitoring. The monitoring physician should be licensed in the state and privileged to interpret neurophysiologic testing in the hospital in which the surgery is being performed. He/she is responsible for real-time interpretation of neurophysiologic intraoperative monitoring data. The monitoring physician should be present in the operating room or have access to intraoperative neurophysiologic monitoring data in real-time from a remote location and be in communication with the staff in the operating room. There are many methods of remote monitoring, however any method used must conform to local and national protected health information guidelines. The specifics of this availability (i.e., types of surgeries) should be decided by the hospital credentialing committee. In order to devote the needed attention, it is recommended that the monitoring physician interpret no more than three cases concurrently.”

American Head and Neck Society

In 2022, the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group published a clinical review of intraoperative nerve monitoring during pediatric thyroid surgery. The review stated that intraoperative neurophysiologic monitoring can be considered in all pediatric thyroid surgeries. Procedures for which monitoring may be most beneficial include: total thyroidectomy, hemithyroidectomy in which the contralateral vocal cord is paralyzed, and re-operative surgeries.

American Society of Neurophysiological Monitoring

In 2018, the American Society of Neurophysiological Monitoring (ASNM) published practice guidelines on the supervising professional on IONM. The ASNM 2013 position statement on intraoperative MEP monitoring indicated that MEPs are an established practice option for cortical and subcortical mapping and for monitoring during surgeries risking motor injury in the brain, brainstem, spinal cord or facial nerve.

National Institute for Health and Care Excellence

A 2008 guidance from the National Institute for Health and Care Excellence on intraoperative neurophysiologic monitoring during thyroid surgery found no major safety concerns. Regarding efficacy, IONM was indicated as helpful “in performing more complex operations such as reoperative surgery and operations on large thyroid glands.

Scoliosis Research Society

In 2020, the Scoliosis Research Society published an information statement on neurophysiologic monitoring during spinal deformity surgery. The Society concluded that neurophysiologic monitoring can allow for early detection of complications and possibly prevent postoperative neurologic injury, and is considered optimal care when the spinal cord is at risk, which warrants a strong recommendation unless there are contraindications. The standard method of intraoperative monitoring should include transcranial motor evoked potentials and somatosensory evoked potentials with or without electromyographic monitoring.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Intra-operative neurophysiologic monitoring, IONM, sensory-evoked potentials, somatosensory-evoked potentials (SSEPs), Brainstem auditory-evoked potentials (BAEPs), Visual-evoked potentials (VEPs), Electromyogram (EMG), Motor-evoked potential, electroencephalogram (EEG), electrocorticography (ECoG), nerve conduction velocity, transcranial magnetic stimulation, Digitimer electrical cortical stimulator

APPROVED BY GOVERNING BODIES:

A number of EEG and EMG monitors have been cleared for marketing by the FDA through the 510(k) process.

Intraoperative neurophysiologic monitoring of motor-evoked potentials using transcranial magnetic stimulation does not have FDA approval.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan. 

CURRENT CODING:

CPT codes:   

95829	Electrocorticogram at surgery (separate procedure)
95865	Needle electromyography; larynx
95867	Needle electromyography; cranial nerve supplied muscle(s), unilateral
95868	Needle electromyography; cranial nerve supplied muscles, bilateral
95885	Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to code for primary procedure)
95886	; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for primary procedure)
95887	Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (list separately in addition to code for primary procedure)
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) checkerboard or flash testing, central nervous system glaucoma, with interpretation and report.
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)
95955	Electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery)

HCPCS codes:

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)

CPT Codes 95940 and 95941 and HCPCS Code G0453 would be reported in conjunction with the code(s) for the testing performed, i.e., 92653, 95822, 95860-95870, 95907-95913, and 95925-95939.

REFERENCES:

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2. Ajiboye RM, Zoller SD, Sharma A, et al. intraoperative neuromonitoring for anterior cervical spine surgery: What is the evidence? Spine (Phila Pa 1976). Mar 15 2017; 42(6):385-393.
3. Alemo S, Sayadipour A. Role of intraoperative neurophysiologic monitoring in lumbosacral spine fusion and instrumentation: a retrospective study. World Neurosurg. Jan 2010; 73(1): 72-6; discussion e7.
4. American Academy of Neurology. Principles of Coding for Intraoperative Neurophysiologic Monitoring (IOM) and Testing Model Policy. 2012. www.aan.com/siteassets/home-page/tools-and- resources/practicing-neurologist--administrators/billing-and-coding/model-coverage- policies/16iommodelpolicy_tr.pdf.
5. American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS). Joint Section on Disorders of the Spine and Peripheral Nerves updated position statement: intraoperative electrophysiological monitoring. January 2018. spinesection.org/about/position-statements/interoperative-electrophysiological-monitoring/.
6. American Clinical Neurophysiology Society.  Guideline 11A.  Recommended Standards for Neurophysiologic Intraoperative Monitoring—Principles. www.acns.org/pdf/guidelines/Guideline-11A.pdf. 
7. American Association of Neuromuscular & Electrodiagnostic Medicine. Position Statement: Recommended Policy for Electrodiagnostic Medicine. Updated 2023. ww.aanem.org/Advocacy/Position-Statements/Recommended-Policy-for-Electrodiagnostic-Medicine. 
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11. Chen B, Yang T, Wang W, et al. Application of Intraoperative Neuromonitoring (IONM) of the Recurrent Laryngeal Nerve during Esophagectomy: A Systematic Review and Meta-Analysis. J Clin Med. Jan 10 2023; 12(2). 
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20. Erwood MS, Hadley MN, Gordon AS, et al. Recurrent laryngeal nerve injury following reoperative anterior cervical discectomy and fusion: a meta-analysis. J Neurosurg Spine. Aug 2016; 25(2):198-204.
21. Feng B, Qiu G, Shen J, et al. Impact of multimodal intraoperative monitoring during surgery for spine deformity and potential risk factors for neurological monitoring changes. J Spinal Disord Tech. Jun 2012; 25(4): E108-14. 
22. Fujimoto D, Taniguchi K, Kobayashi H. Intraoperative neuromonitoring during prone thoracoscopic esophagectomy for esophageal cancer reduces the incidence of recurrent laryngeal nerve palsy: a single-center study. Updates Surg. Apr 2021; 73(2): 587-595.
23. Halsey MF, Myung KS, Ghag A, et al. Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement. Spine Deform. Aug 2020; 8(4): 591-596.
24. Henry BM, Graves MJ, Vikse J, et al. The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses. Langenbecks Arch Surg. Jun 2017; 402(4):663-673.
25. Hikage M, Kamei T, Nakano T, et al. Impact of routine recurrent laryngeal nerve monitoring in prone esophagectomy with mediastinal lymph node dissection. Surg Endosc. Jul 2017; 31(7): 2986-2996
26. Huang CL, Chen CM, Hung WH, et al. Clinical Outcome of Intraoperative Recurrent Laryngeal Nerve Monitoring during Thoracoscopic Esophagectomy and Mediastinal Lymph Node Dissection for Esophageal Cancer. J Clin Med. Aug 23 2022; 11(17).
27. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
28. Jahangiri FR. Multimodality neurophysiological monitoring during tibial/fibular osteotomies for preventing peripheral nerve injuries. Neurodiagn J. June 2013; 53(2):153-68.
29. Kneist W, Kauff DW, Juhre V, et al. Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study. Eur J Surg Oncol. Sep 2013; 39(9):994-999.
30. Kneist W, Kauff DW, Rubenwolf P, et al. Intraoperative monitoring of bladder and internal anal sphincter innervation: a predictor of erectile function following low anterior rectal resection for rectal cancer? Results of a prospective clinical study. Dig Surg. 2013; 30(4-6):459-465.
31. Kobayashi H, Kondo M, Mizumoto M, et al. Technique and surgical outcomes of mesenterization and intra-operative neural monitoring to reduce recurrent laryngeal nerve paralysis after thoracoscopic esophagectomy: A cohort study. Int J Surg. Aug 2018; 56: 301-306. 
32. Komatsu S, Konishi T, Matsubara D, et al. Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer. J Gastrointest Surg. Dec 2022; 26(12): 2444-2450.
33. Kundnani VK, Zhu L, Tak H, et al. Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases. Indian J Orthop. Jan 2010; 44(1): 64-72. 
34. Lo YL, Dan YF, Teo A, et al. The value of bilateral ipsilateral and contralateral motor evoked potential monitoring in scoliosis surgery. Eur Spine J. Sep 2008; 17 Suppl 2(Suppl 2): S236-8.
35. Luk KD, Hu Y, Wong YW, et al. Evaluation of various evoked potential techniques for spinal cord monitoring during scoliosis surgery. Spine (Phila Pa 1976). Aug 15 2001; 26(16): 1772-7.
36. Luo W, Zhang F, Liu T, et al. Minimally invasive transforaminal lumbar interbody fusion aided with computer-assisted spinal navigation system combined with electromyography monitoring. Chin Med J (Engl). Nov 2012; 125(22): 3947-51. 
37. Macdonald DB, Al Zayed Z, Al Saddigi A. Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries. Eur Spine J. Nov 2007; 16 Suppl 2(Suppl 2): S171-87.
38. Macdonald DB, Skinner S, Shils J et al. Intraoperative motor evoked potential monitoring - A position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol. Dec 2013; 124(12):2291-316 
39. Maguire J, Wallace S, Madiga R, et al. Evaluation of intrapedicular screw position using intraoperative evoked electromyography. Spine (Phila Pa 1976). May 01 1995; 20(9): 1068-74.
40. Melachuri SR, Melachuri MK, Anetakis K, et al. Diagnostic Accuracy of Thresholds Less Than or Equal to 8 mA in Pedicle Screw Testing During Lumbar Spine Procedures to Predict New Postoperative Lower Extremity Neurological Deficits. Spine (Phila Pa 1976). Jan 15 2021; 46(2): E139-E145. 
41. Nagda SH, Rogers KJ, Sestokas AK et al. Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring. J Shoulder Elbow Surg 2007; 16(3 Suppl):S2-8.
42. National Institute for Health and Care Excellence. Intraoperative nerve monitoring during thyroid surgery. 2008.
43. Noonan KJ, Walker T, Feinberg JR, et al. Factors related to false- versus true-positive neuromonitoring changes in adolescent idiopathic scoliosis surgery. Spine (Phila Pa 1976). Apr 15 2002; 27(8): 825-30.
44. Nuwer MR, Emerson RG, Galloway G et al. Evidence-based guideline update:  intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society.  Neurology 2012; 78(8):585-9.
45. Ochs BC, Herzka A, Yaylali I. Intraoperative neurophysiological monitoring of somatosensory evoked potentials during hip arthroscopy surgery. Neurodiagn J 2012; 52(4):312-9.
46. Papadopoulos EC, Girardi FP, Sama A, et al. Accuracy of single-time, multilevel registration in image-guided spinal surgery. Spine J. 2005; 5(3): 263-7; discussion 268. 
47. Pardal-Refoyo JL, Ochoa-Sangrador C. Bilateral recurrent laryngeal nerve injury in total thyroidectomy with or without intraoperative neuromonitoring. Systematic review and meta-analysis. Acta Otorrinolaringol Esp. Mar-Apr 2016; 67(2):66-74.
48. Pastorelli F, Di Silvestre M, Plasmati R, et al. The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. Eur Spine J. May 2011; 20 Suppl 1(Suppl 1): S105-14.
49. Péréon Y, Bernard JM, Fayet G, et al. Usefulness of neurogenic motor evoked potentials for spinal cord monitoring: findings in 112 consecutive patients undergoing surgery for spinal deformity. Electroencephalogr Clin Neurophysiol. Jan 1998; 108(1): 17-23. 
50. Pisanu A, Porceddu G, Podda M, et al. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. May 1 2014; 188(1):152-161.
51. Reddy RP, Chang R, Coutinho DV, et al. Triggered Electromyography is a Useful Intraoperative Adjunct to Predict Postoperative Neurological Deficit Following Lumbar Pedicle Screw Instrumentation. Global Spine J. Jun 2022; 12(5): 1003-1011. 
52. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine. Jun 2005; 2(6):725-732.
53. Schwartz DM, Auerbach JD, Dormans JP et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am 2007; 89(11):2440-9.
54. Sharan A, Groff MW, Dailey AT, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine 2014.
55. Skinner SA, Cohen BA, Morledge DE, et al. Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring. J Clin Monit Comput. Apr 2014; 28(2):103-111.
56. Sun W, Liu J, Zhang H, et al. A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations. Clin Endocrinol (Oxf). Nov 2017; 87(5):572-580.
57. Sutter MA, Eggspuehler A, Grob D, et al. Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients. Eur Spine J. Nov 2007; 16 Suppl 2(Suppl 2): S221-8.
58. Takeda S, Iida M, Kanekiyo S, et al. Efficacy of intraoperative recurrent laryngeal neuromonitoring during surgery for esophageal cancer. Ann Gastroenterol Surg. Jan 2021; 5(1): 83-92. 
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POLICY HISTORY:

Medical Policy Group, March 2007 (3)

Medical Policy Administration Committee, April 2007

Available for comment April 12-May 26, 2007

Medical Policy Group, March 2009 (1)

Medical Policy Group, June 2009 (2)

Medical Policy Administration Committee, July 2009

Available for comment July 1-August 14, 2009

Medical Policy Panel, July 2011

Medical Policy Group, August 2011 (2): Update Description, Key Points, Key Words, Government Approval, References

Medical Policy Administration Committee, August 2011

Available for comment August 11 – September 26, 2011

Medical Policy Group, December 2011 (3): Added new 2012 Codes – 95885, 95886, 95887

Medical Policy Panel, March 2012

Medical Policy Group, September 2012 (2); Policy statements changed to indicate motor-evoked potentials using transcranial electrical stimulation meets coverage criteria and motor-evoked potential using transcranial magnetic stimulation is investigational.  Key Points and References updated to support Policy changes.

Medical Policy Administration Committee, September 2012

Available for comment September 18 through October 31, 2012

Medical Policy Group, November 2012: Added new 2013 Codes G0453, 95940, 95941, 95907, 95908, 95909, 95910, 95911, 95912, & 95913 effective January 1, 2013; Deleted Codes 95920, 95900, 95903, & 95904 effective January 1, 2013.

Medical Policy Panel, December 2012

Medical Policy Group, August 2013 (2): Updated Key Points and References from literature search through October 2012.   No change in policy statement. 

Medical Policy Panel, May 2014

Medical Policy Group, July 2014 (4): Updated Key Points and References. No changes to the policy at this time.

Medical Policy Panel, May 2015

Medical Policy Group, May 2015 (6):  Updates to Key Points, Approved by Governing Bodies, and References; no change to policy statement.

Medical Policy Group, March 2016 (6):  Clarification to policy statement; no change in policy intent.

Medical Policy Group, July 2016: Removed Policy section prior to November 1, 2012 in policy cleanup.

Medical Policy Panel, May 2017

Medical Policy Group, June 2017 (6): Updates to Description, Policy statement edited to allow coverage for monitoring of the Recurrent Laryngeal Nerve, Key points, Key Words, Practice Guidelines, Governing Bodies, Coding, and References.

Medical Policy Group, December 2017. Annual Coding Update 2018. Updated verbiage for revised CPT Code 95930.

Medical Policy Panel April 2018

Medical Policy Group, May 2018 (6): Updates to Key Points and References.

Medical Policy Group, October 2018 (3): Corrected Typo; Removed double underline; Added note in the coding section for processing guidelines for CPT codes 95940, 95941 and HCPCS Code G0453.

Medical Policy Panel, April 2019

Medical Policy Group, May 2019 (3): 2019 Updates to Key Points, Practice Guidelines and Position Statements, References, and Key Words: added IONM. Revised policy statement for clarification of criteria. Removed third criteria point in policy statement related to physician monitoring and interpretation of cases. Placed on DRAFT May 13, 2019 for 45 days for comment.

Medical Policy Panel, April 2020

Medical Policy Group, May 2020 (3): 2020 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Group, November 2020: Annual Coding Update. Moved CPT codes 92585 and 92586 from Current coding section. Created Previous Coding section to include codes 92585 and 92586.

Medical Policy Panel, April 2021

Medical Policy Group, May 2021 (3): 2021 Updates to Key Points and Practice Guidelines and Position Statements. Policy statement updated to remove “not medically necessary,” no other changes to policy statement or intent.

Medical Policy Group, March 2022 (3): 2022 Updates to Key Points, Practice Guidelines and Position Statements, and References. Policy statement revised to allow coverage for remote monitoring that must be conducted and interpreted in real-time with continuous communication to the surgical team. 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 monitoring physician.

Medical Policy Administration Committee, April 2022

Available for comment April 1, 2022 through May 14, 2022. Effective May 15, 2022.

Medical Policy Panel, April 2023

Medical Policy Group, May 2023 (3): 2023 Updates to Description, Key Points, Practice Guidelines and Position Statements, Benefit Applications, Approved by Governing Bodies, and References. Previous Coding section removed. No changes to policy statement or intent.

Medical Policy Panel, April 2024

Medical Policy Group, April 2024 (3): Updates to Description, Key Points, and References. No changes to policy statement or intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.