22586
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
27.42
Facility
$2008.06
Non-Facility
$2008.06
Documentation Required
- No explicit documentation requirements (e.g., required medical records, test results, or specific clinical notes) are specified in this policy.
- From Instructions for Use: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- From Instructions for Use: "This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5)."
Key Coverage Criteria
- No explicit "Covered Indications" or "Medically Necessary" indications are provided in this policy document.
- Coverage decisions are to be determined by the member specific benefit plan document (see Instructions for Use).
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is performed by either a licensed physician trained in clinical neurophysiology (e.g., a neurologist, physiatrist) 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 i [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is 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 electroneurodiagnostic (END) monitoring situations and is immediately available to interpret the recording [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: Monitoring is conducted and interpreted real-time (either on-site or at a remote location) and continuously communicated to the surgical team.
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: There is significant risk of brain, spinal cord, cranial nerve, or major peripheral nerve injury during a surgical procedure.
11 Active Policies
UHC-POL-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
UMR-POL-UMR-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
SUREST-POL-SUREST-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
CIGNA-0509 — Intraoperative Monitoring - (0509)
Related Codes
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