Humana Intraoperative Neurological Monitoring Form

Description

Intraoperative neurological monitoring is the recording of nerve signals and brainwaves during surgery, to monitor and thereby reduce the risk of significant nerve damage. It is 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 (eg, carotid endarterectomies and thoracic abdominal aortic aneurysm repair) and some ear/nose/throat (ENT) procedures.

Intraoperative neurological monitoring may utilize the following testing methods depending on the type of surgery being performed:

• Brain auditory evoked potential (BAEP), also known as auditory brainstem response, is a recording of the electrical activity from the brainstem. The test involves the use of sound to stimulate pathways in the brain and record the electrical response. It provides basic information about whether sounds are reaching the brainstem.
• Electroencephalogram (EEG) testing measures and records the electrical activity of the brain, by placing electrodes on the scalp/head; most commonly used when a physician is trying to establish the presence of a seizure disorder.
• Electromyogram (EMG) testing measures the electrical activity produced by a muscle contraction, to evaluate nerve and muscle function. It does not pertain to a nerve impulse traveling to or from the brain, but is an evaluation of the electrical activity of the muscle and the associated nerve.
• Motor evoked potential (MEP) monitoring is used to evaluate motor nerve pathway integrity. It is often described as the opposite of somatosensory evoked potential testing. Electrodes are placed on the arms or legs and an electrical current is used to stimulate the motor center of the brain. The length of time it takes for the signal to travel to the muscle being tested and the resulting muscle contraction is then observed and recorded.

Somatosensory evoked potentials (SSEP) monitoring evaluates the sensory nerve pathway from the arms and legs through the spinal cord to the brain. This is accomplished by attaching electrodes to the scalp and along the nerve pathway on the neck and shoulders. An electrical current is then sent through a probe to the skin near a nerve in the wrist or ankle. The length of time it takes the electrical signal to travel through the nerve pathway to the brain is recorded and monitored.

• Visual evoked potentials (VEP), also known as visual evoked responses (VER), measure and record the function of the optic nerve or central nervous system to identify interruptions in transmission along the optic nerve pathway. (Refer to Coverage Limitations section)

Surface electromyography (SEMG) may be performed intraoperatively using the US Food & Drug Administration (FDA) approved EPAD 2 system. In addition, the intraoperative neurological monitoring system may record SSEPs or assess the neuromuscular junction (NMJ). The system consists of a headbox attaching onto the operating table, electrodes, probes and a mobile touchscreen tablet for user input and display of output (eg, waveforms).

Intraoperative Neurological Monitoring

Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0336-023

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

SEMG is a noninvasive computer-based technique recording electrical impulses using surface electrodes and conduction gel placed on the skin overlying the nerve measuring at rest and during activity.⁴⁸ (Refer to Coverage Limitations section)

This policy addresses neurological monitoring that takes place during surgery; for other types of neurological monitoring, please refer to the Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for intraoperative neurological monitoring (BAEP, EEG, EMG, MEP, SEP) during spinal, neurologic, cranial or vascular procedures that may compromise neurologic function when the following criteria are met:

• Monitoring is requested by the operating surgeon; AND
• Monitoring is performed by either a licensed physician trained in clinical neurophysiology (eg, neurologist, physiatrist) or by a trained technologist who is practicing according to licensure/certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology; AND
• Monitoring is interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon, providing real time supervision and interventional recommendations while monitoring one on one in the operating room or remotely*; AND
• Monitoring period includes only intraoperative time. This time, however, may be cumulative and does not have to be continuous, for example, 30 minutes of continuous attendance followed by another 30 minutes of continuous attendance later in the procedure will constitute 1 hour of monitoring

*Physician can monitor NO more than three cases simultaneously for the covered indications listed below.

Intraoperative Neurological Monitoring

Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0336-023

Page: 4 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Indications for which intraoperative monitoring MAY be utilized include:

• Aortic arch and the branch vessels surgical procedures; OR
• Arteriography during which there is a test occlusion of the carotid artery; OR
• Brachial plexus surgery; OR
• Bronchial artery arteriovenous malformations or tumor embolization; OR
• Carotid artery revascularization procedures (eg, endarterectomy, stenting); OR
• Circulatory arrest with hypothermia (does not include procedures under circulatory bypass – coronary artery bypass graft, ventricular aneurysms); OR
• Correction of cerebral vascular aneurysms; OR
• Correction of intracranial or spinal arteriovenous malformations; OR
• Correction of scoliosis; OR
• Deep brain stimulation; OR
• Descending aortic open surgical and endovascular procedures (eg, thoracic or thoracoabdominal aortic aneurysm repair); OR
• High risk thyroid surgery (eg, complete resection of a lobe, resection of entire gland, reoperation or retrosternal approach); OR
• Leg lengthening procedures involving traction on the femoral, peroneal or sciatic nerve; OR
• Meniere disease surgical procedures (eg, endolymphatic shunt, vestibular neurectomy); OR
• Multi-level cervical fusions with instrumentation; OR

Intraoperative Neurological Monitoring

Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0336-023

Page: 5 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Peripheral nerve neuromas of the brachial plexus with risk to major sensory or motor nerves; OR
• Protection of cranial nerves during the following procedures:
  • Cavernous sinus tumor removal
  • Foramen magnum surgery
  • Microvascular decompression
  • Oval or round window graft
  • Removal of tumors involving the cranial nerves
  • Skull base surgery in the vicinity of the cranial nerves; OR
• Removal of brain tissue close to the primary motor cortex and requiring brain mapping; OR
• Removal of epileptogenic brain tissue or tumor; OR
• Removal of spinal tumors; OR
• Spinal fractures with risk of cord compression; OR
• Spinal procedures that pose a risk of significant damage to an essential central nervous system structure (artificial cervical or lumbar disc replacement, removal of old hardware, reoperation); OR
• Tethered cord release; OR
• Traumatic injury to the brain or spinal cord

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, GE NMT, 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.

Intraoperative Neurological Monitoring

Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0336-023

Page: 6 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Note: The criteria for intraoperative neurological monitoring are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information

Coverage Limitations

Humana members may NOT be eligible under the Plan for intraoperative neurological monitoring (BAEP, EEG, EMG, MEP, SEP) for any indications other than those listed above including, but may not be limited to:

• Cardiac surgery; OR
• Routine cervical/lumbar/thoracic fusion; OR
• Routine cervical/lumbar/thoracic laminectomy (eg, decompressive laminectomy for stenosis); OR
• Routine decompression or discectomy for disc herniation

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for intraoperative VEP monitoring for any indications. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for intraoperative SEMG monitoring (eg, EPAD 2) for any indications. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Intraoperative Neurological Monitoring

Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0336-023

Page: 7 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about cranial, neurological, spinal or vascular procedures may be found from the following websites:

• Background
• American Association of Neurological Surgeons
• National Library of Medicine
• Society of Vascular Surgery

Medical Alternatives

Alternatives to intraoperative neurological monitoring include, but may not be limited to:

• Wake-up test (the individual is awakened during surgery and asked to move their legs or arms)

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.