96003
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- No specific documentation requirements are stated in the provided CPB text.
- Standard clinical documentation would apply, but the CPB does not list required medical records, test results, or specific documentation that would render these procedures covered.
- No specific documentation requirements are stated in this Clinical Policy Bulletin.
- Documentation must support that BOTH coverage criteria are met: (1) child or adolescent with a diagnosis of cerebral palsy, and (2) the procedure is being performed as part of a preoperative assessment with results to be used in surgical planning.
Key Coverage Criteria
- Instrumented gait analysis collecting kinetic, kinematic and poly-EMG data for preoperative planning in patients with upper motor neuron syndrome and gait dysfunction (example: spastic equinovarus deformity of the foot and ankle).
- Clinical evaluation and treatment planning for ambulatory children with cerebral palsy (including confirmation of clinical indications for surgery, defining indications not clinically proposed, and excluding or delaying clinically proposed surgery).
- Evaluation of walking (simple and dual task) in patients with mild cognitive impairment (MCI) and mild Alzheimer's disease (AD) (to define specific gait patterns for each cognitive profile).
- Kinematic gait analysis as a potential outcome measure in knee or hip osteoarthritis (OA) (measuring gait parameters such as dynamic joint angles, gait speed, and stride length).
- Kinematic and kinetic gait pattern comparison in children with autism versus age-matched controls (to quantify gait abnormalities).
- Dynamic electromyography (EMG) as part of comprehensive motion analysis for pre-operative planning (noted as used but with uncertain proven utility).
3 Active Policies
AETNA-CPB-0263 — Gait Analysis and Electrodynogram
CIGNA-0315 — Gait Analysis - (0315)
AETNA-CPB-0294 — Pedobarography
Related Codes
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