Gait Analysis Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|03|2015 POLICY LAST REVIWED: 01|21|2026 OVERVIEW Gait analysis is the quantitative laboratory assessment of coordinated muscle function, typically requiring a dedicated facility and staff and analysis of a video-recorded observation of a patient walking. Gait analysis has been proposed as an aid in surgical planning, primarily for children with cerebral palsy. It is also a potential tool to help plan rehabilitative strategies for ambulatory problems related to cerebral palsy, aging, stroke, spinal cord injury, and other conditions. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Gait analysis is covered with a diagnosis of cerebral palsy. For all other indications, it is considered not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products Gait analysis is covered with a diagnosis of cerebral palsy. For all other indications, it is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.
BACKGROUND: Gait analysis is the quantitative assessment of coordinated muscle function. Evaluation is conducted in a laboratory and typically involves a dedicated facility and staff. A visual assessment of walking is supplemented by video recording. Videos can be observed from several visual planes at slow speed, allowing detection of movements not observable at normal speed. Joint angles and various time-distance variables, including step length, stride length, cadence, and cycle time, can be measured. Electromyography (EMG), assessed during walking, measures timing and intensity of muscle contractions. This calculation allows determination of whether a certain muscle’s activity is normal, out of phase, continuous, or clonic. Kinematics is the term used to describe movements of joints and limbs, such as angular displacement of joints and angular velocities and accelerations of limb segments. The central element of kinematic assessment is some type of marker system that is used to represent anatomic landmarks, which are then visualized and quantitatively assessed during analysis of videotaped observations. Movement data are compiled by computer from cameras oriented in several planes, and the movement data are processed so that the motion of joints and limbs can be assessed in 3 dimensions. The range and direction of motion of a particular joint can be isolated from all the other simultaneous motions that are occurring during walking. Graphic plots of individual joint and limb motion as a function of gait phase can be generated. Medical Coverage Policy | Gait Analysis

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Kinetics is the term used to describe those factors that cause or control movement. Evaluating kinetics involves the use of principles of physics and biomechanics to explain the kinematic patterns observed and to generate analyses that describe the forces generated during normal and abnormal gait analysis.

Gait analysis has been proposed as an aid in surgical planning, primarily for cerebral palsy but also for other conditions, such as clubfoot. In addition, gait analysis is being investigated as a means to plan rehabilitative strategies (i.e., orthotic-prosthetic devices) for ambulatory problems related to cerebral palsy, aging, stroke, spinal cord injury, etc.

Gait analysis is the quantitative assessment of coordinated muscle function. For patients with cerebral palsy undergoing surgery for gait disorders, one randomized controlled trial did not find improvement in health outcomes for patients who received gait analysis as part of surgical planning, and one non-randomized controlled trial did not find improvement in utilization parameters. Several studies conducted among patients with cerebral palsy and other conditions suggest that gait analysis recommendations impact treatment decisions, but the impact of these decisions on health outcomes is as yet unknown. Based on input from clinical reviewers, gait analysis, when comprehensive, may be medically necessary for planning prior to surgery in children with gait disorders associated with cerebral palsy. For all other indications, gait analysis is considered not medically necessary due to no proven efficacy.

CODING Medicare Advantage Plans and Commercial Products The following CPT code(s) are considered medically necessary when filed with the below diagnosis codes*: 96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics
96001 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking
96002 Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
96004 Physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report.

*ICD-10-CM codes:
G80.0-G80.9

RELATED POLICIES None

PUBLISHED Provider Update, March 2026 Provider Update, March 2025 Provider Update, March 2024 Provider Update, April 2023 Provider Update, June 2022

REFERENCES

1. Cutti A, Ferrari A, Garofalo P et al. ‘Outwalk’: a protocol for clinical gait analysis based on inertial and magnetic sensors. Med Biol Eng Comput 2010; 48(1):17-25.
2. van den Noort JC, Ferrari A, Cutti AG et al. Gait analysis in children with cerebral palsy via inertial and magnetic sensors. Med Biol Eng Comput 2013; 51(4):377-86.
3. Dobson F, Morris ME, Baker R et al. Gait classification in children with cerebral palsy: a systematic review.
   Gait Posture 2007; 25(1):140-52.
4. Noonan KJ, Halliday S, Browne R et al. Interobserver variability of gait analysis in patients with cerebral palsy. J Pediatr Orthop 2003; 23(3):279-87.
5. Wren TA, Otsuka NY, Bowen RE et al. Outcomes of lower extremity orthopedic surgery in ambulatory children with cerebral palsy with and without gait analysis: Results of a randomized controlled trial. Gait Posture 2012 [Epub ahead of print].

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

6. Wren TA, Kalisvaart MM, Ghatan CE et al. Effects of preoperative gait analysis on costs and amount of surgery. J Pediatr Orthop 2009;29(6):558-63.
7. Lofterod B, Terjesen T, Skaaret I et al. Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients. Acta Orthop 2007; 78(1):74-80.
8. Lofterod B, Terjesen T. Results of treatment when orthopaedic surgeons follow gait- analysisrecommendations in children with CP. Dev Med Child Neurol 2008; 50(7):503-9.
9. Gough M, Shortland AP. Can clinical gait analysis guide the management of ambulant children with bilateral spastic cerebral palsy? J Pediatr Orthop 2008; 28(8):879-83.
10. Wren TA, Gorton GE, Ounpuu S et al. Efficacy of clinical gait analysis: a systematic review. Gait Posture
    2011; 34(2):149-53.
11. Suda Y, Saitou M, Shibasaki K et al. Gait analysis of patients with neurogenic intermittent claudication. Spine 2002; 27(22):2509-13.
12. Sankar WN, Rethlefsen SA, Weiss J et al. The recurrent clubfoot: can gait analysis help us make better preoperative decisions? Clin Orthop Relat Res 2009; 467(5):1214-22.

13. Sponsored by the Hospital for Sick Children. Outcomes of orthopedic surgery using gait laboratory versus observational gait analysis in children with cerebral palsy (NCT00419432). Available online at: www.clinicaltrials.gov. Last accessed January, 2013.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS