UPMC Health Plan POLICY AND PROCEDURE MANUAL POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 1 of 13 SUBJECT: INDEX TITLE: ORIGINAL DATE: Intraoperative Neurophysiological Testing Medical Management February 2010 This policy applies to the following lines of business: (Check those that apply.) COMMERCIAL CMS-MA DPW-MA ANCILLARY HMO ( ) WV ( ) Health Choices /PH ( ) Dental ( ) PPO ( ) PA ( ) Health Choices/BH ( ) Vision ( ) Fully Insured ( ) All (X) All ( ) COBRA ( ) Self-funded/ASO ( ) All ( ) Indiv. Product ( ) PID-CHIP WORK PARTNERS All (X) HMO (X) CHIP (X) Commercial WC ( ) PPO (X) Disability Svcs/TPA ( ) CSNP (X) Health Promotion ( ) DSNP (X) All ( ) CDHP ISNP (X) HSA ( ) LIFE SOLUTIONS Part D ( ) HRA ( ) LifeSolutions ( ) All ( ) HIA ( ) All ( ) I. POLICY It is the policy of UPMC Insurance Services Division to cover Intraoperative Neurophysiological Testing (IONT) when it is medically necessary as detailed in this policy and covered under the member’s specific benefit plan. II. DEFINITIONS Clinically Trained Neurophysiologist is a physician (MD or DO) board certified in Neurology or Neurosurgery who has completed an accredited fellowship in clinical neurophysiology and/or intraoperative neurophysiological monitoring. III. PURPOSE The purpose of this policy is to determine the indications for coverage of Intraoperative Neurophysiological Testing. Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 2 of 13 IV. SCOPE This policy applies to various UPMC Insurance Services Division Departments as indicated by the Benefit and Reimbursement Committee. These include but are not limited to Medical Management, Benefit Configuration and Claims Departments. V. PROCEDURE A. Medical Description / Background Intraoperative neurophysiological testing describes ongoing electrophysiologic testing and monitoring performed during surgical procedures on the nervous system, its blood supply, or adjacent tissue to prevent unintentional damage to critical neurologic structures. It is a recognized medical practice standard for almost 30 years although randomized controlled trials establishing efficacy of it have not been done. Intraoperative neurophysiological monitoring (IONM) consists of the use of electroencephalography (EEG), evoked potentials (such as cranial nerve, brain-stem auditory, motor or somatosensory EP’s), and/or electromyography (EMG) to monitor the function of neural structures. The goal is to identify changes in the brain, spinal cord, and peripheral nerve function prior to irreversible damage. It is also used to localize anatomical structures which help guide the surgeon during dissection and can demonstrate which nerves are still functional versus compromised. Monitoring, if used to assess sensory/motor pathways, should access the appropriate pathway because inappropriate monitoring could result in an adverse outcome. Some high risk patients may only be approved for surgery if IONM is performed. IONM may be used in neurosurgery, orthopedic, vascular, cardiothoracic, and other surgical specialties. The quality, extent, and type of monitoring are dependent on the nature and location of the surgery or lesions. IONM by non-physician personnel (a specifically trained technician registered with one of the credentialing organizations such as the American Board of Neurophysiology Monitoring or the American Board of Registration of Electrodiagnostic Technologists) must be performed under the direct supervision of a physician trained in neurophysiologic techniques who is available to interpret the studies and advise the surgeon during the operative procedure. B. Indications include ANY of the following: • • • • Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is a risk of cerebral or spinal cord ischemia Resection of epileptogenic brain tissue or tumor Resection of brain tissue close to the primary motor cortex and requiring brain mapping Protection of cranial nerves: 1. tumors that affect optic, trigeminal, facial, auditory nerves Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 3 of 13 • • • • • • • • • • • • • • • • • 2. cavernous sinus tumors 3. microvascular decompression of cranial nerves 4. oval or round window graft 5. endolymphatic shunt for Meniere’s disease 6. vestibular section for vertigo 7. laryngeal nerve for thyroid surgeries Correction of scoliosis or deformity of spinal cord involving traction on the cord Protection of spinal cord where work is performed in close proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions Spinal instrumentation requiring pedicle screws or distraction Decompression procedures on the spinal cord or cauda equine carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk Spinal cord tumors Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves Surgery or embolization for intracranial arteriovenous AV malformations Surgery for arteriovenous malformation of spinal cord Cerebral vascular aneurysms Surgery for intractable movement disorders Arteriography, during which there is a test occlusion of the carotid artery Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass (e.g., CABG, ventricular aneurysms) Distal aortic procedures, where there is risk of ischemia to spinal cord Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks Basal ganglia movement disorders Surgery as a result of traumatic injury to spinal cord/brain Deep brain stimulation C. Limitations include all of the following: • The test must be requested by the operating surgeon and the monitoring must be performed by a clinically trained neurophysiologist (MD/DO) other than the operating surgeon, the surgical assistant, or the anesthesiologist rendering the anesthesia due to the high potential for morbidity. Claims submission must include documentation for the time devoted to direct monitoring of the patient (time may be cumulative). • A technologist must be present continuously in the operating suite recording and monitoring a single case under the neurophysiologist’s supervision. This technologist must have either the physical or electronic capacity for real-time communication with the supervising neurophysiologist. Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 4 of 13 • The surgical team and the monitoring staff must always be able to be in immediate contact with each other. • Services must be performed in the inpatient setting only. • Intraoperative monitoring is not medically necessary in situations where historical data and current practices reveal no potential to neural integrity during surgery. • For coverage of remote monitoring (as mentioned above) the neurophysiologist must have immediate physical or real-time communication with the operating room. He/she must have the ability to watch the tracings as they are obtained in real-time in the operating room as well as the baseline electrophysiological test and the monitoring tracings from earlier in the case. • The monitoring physician must have a plan in place to transfer care to another physician, should any other situation arise during patient monitoring. • Technical criteria – it is mandatory that at least 8 recording channels (16 if EEG is monitored) be available for all IONM. The equipment utilized must also provide for all of the monitoring modalities that are needed such as auditory-evoked response, electroencephalography/electrocorticography, electromyography/nerve conduction, and somatosensory-evoked response. D. Codes The following codes for treatments and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. CPT Coding: CPT Code: 95940 *95941 G0453 Description: Continuous intraoperative neurosphysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure and in conjunction with the study performed) Continuous intraoperative neurosphysiology monitoring, from outside the operating room (remote or nearby) or for monitor of more than one case within in the operating room, per hour (List separately in addition to code for primary procedure and in conjunction with the study performed) Continuous intraoperative neurophysiology monitoring, from outside Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 5 of 13 the operating room (remote or nearby), per patient, (attention directed exclusively to one patient each 15 minutes (List in addition to primary procedure. *CPT Code 95941 is invalid for Medicare* ICD Coding ICD-9 Code: 170.2 192.0-192.9 193 198.3 198.4 225.0-225.9 237.0 237.1 237.5 237.6 237.7-237.72 237.9 239.6 246.9 324.1 336.0 343.8 343.9 348.4 350.1 350.2 352.0-352.9 353.0 353.1 353.2 353.3 353.4 385.30-385.35 430 431 432.0-432.9 Description: Malignant neoplasm of vertebral column excluding sacrum and coccyx Malignant neoplasm of cranial nerves-malignant neoplasm of nervous system part unspecified Malignant neoplasm of thyroid gland Secondary malignant neoplasm of brain and spinal cord Secondary malignant neoplasm of other parts of nervous system Benign neoplasm of brain-benign neoplasm of nervous system unspecified Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct Neoplasm of uncertain behavior of pineal gland Neoplasm of uncertain behavior of brain and spinal cord Neoplasm of uncertain behavior of meninges Neurofibromatosis unspecified-Neurofibromatosis type 2 acoustic neurofibromatosis Neoplasm of uncertain behavior of other and unspecified parts of nervous system Neoplasm of unspecified nature of brain Unspecified disorder of thyroid Intraspinal abscess Syringomyelia and syringobulbia Other specified infantile cerebral palsy Infantile cerebral palsy unspecified Compression of brain Trigeminal neuralgia Atypical face pain Disorders of cranial nerves Brachial plexus lesions Lumbosacral plexus lesions Cervical root lesions, not elsewhere classified Thoracic root lesions not elsewhere classified Lumbosacral root lesions not elsewhere classified Cholesteatoma unspecified-Diffuse cholesteatosis of middle ear and mastoid Subarachnoid hemorrhage Intracerebral hemorrhage Nontraumatic extradural hemorrhage-unspecified intracranial Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 6 of 13 433.00-433.91 434.00-434.91 435.0-435.9 437.3 437.5 441.00-441.03 441.1-441.9 443.21 443.24 721.1 721.41-721.42 721.91 722.70-722.73 723.0 724.00-724.09 737.10-737.19 737.20 737.22 737.30-737.39 737.40-737.43 737.8 741.00-741.03 747.81 747.82 767.4 767.5 767.6 767.7 806.01-806.09 806.10-806.19 806.20-806.29 hemorrhage Occlusion and stenosis of basilar artery without cerebral infarctionocclusion and stenosis of unspecified precerebral artery with cerebral infarction Cerebral thrombosis without cerebral infarction-cerebral artery occlusion unspecified with cerebral infarction Basilar artery syndrome-unspecified transient cerebral ischemia Cerebral aneurysm nonruptured Moyamoya disease Dissection of aorta aneurysm unspecified site-Dissection of aorta thoracoabdominal Thoracic aneurysm ruptured-aortic aneurysm of unspecified site without rupture Dissection of carotid artery Dissection of vertebral artery Cervical spondylosis with myelopathy Spondylosis with myelopathy thoracic region-spondylosis with myelopathy lumber region Spondylosis of unspecified site with myelopathy Intervertebral disc disorder with myelopathy unspecifiedintervertebral disc disorder with myelopathy lumbar region Spinal stenosis of in cervical region Spinal stenosis other than cervical Kyphosis (acquired) (postural) - other kyphosis acquired Lordosis (acquired) (postural) Other postsurgical lordosis Scoliosis (and kyphoscoliosis) idiopathic-other kyphoscoliosis and scoliosis Unspecified curvature of spine associated with other conditionsscoliosis associated with other conditions Other curvatures of spine associated with other conditions Spina bifida unspecified region with hydrocephalus-spina bifida lumbar region with hydrocephalus Congenital anomalies of cerebrovascular system Spinal vessel anolmaly Injury to spine and spinal cord due to birth trauma Facial nerve injury due to birth trauma Injury to brachial plexus due to birth trauma Other cranial and peripheral nerve injuries due to birth trauma Closed fracture of C1-C4 level with complete lesion of cord-closed fracture of C5-C7 level with other specified spinal cord injury Open fracture of C1-C4 level with unspecified spinal cord injuryopen fracture of C5-C7 level with other specified spinal cord injury Closed fracture of T1-T6 level with unspecified spinal cord-closed fracture of T7-T12 level with other specified spinal cord injury Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 7 of 13 806.30-806.39 806.4 806.5 806.7-806.79 806.8 806.9 850.4 953.0-953.9 955.0-955.9 956.0-956.9 ICD-10 Code: C41.2 C72.0-C72.9 Open fracture of T1-T6 level with unspecified spinal cord injuryopen fracture of T7-T12 level with other specified spinal cord injury Closed fracture of lumbar spine with spinal cord injury Open fracture of lumbar spine with spinal cord injury Open fracture of sacrum and coccyx with unspecified spinal cord injury-open fracture of sacrum and coccyx with other spinal cord injury Closed fracture of unspecified vertebra with spinal cord injury Open fracture of unspecified vertebra with spinal cord injury Concussion with prolonged loss of consciousness without return to pre-existing conscious level Injury to cervical nerve root- injury to unspecified site of nerve roots and spinal plexus Injury to axillary nerve-injury to unspecified nerve of shoulder girdle and upper limb Injury to sciatic nerve- injury to unspecified nerve of pelvic girdle and lower limb D49.9 E07.89 G06.1 Description: Malignant neoplasm of vertebral column Malignant neoplasm of spinal cord, cranial nerves, and other parts of central nervous system Malignant neoplasm of thyroid gland Secondary malignant neoplasm of brain and other parts of nervous system Benign neoplasm for meninges, brain, and other parts of central nervous system Neoplasm of uncertain behavior of pituitary, craniopharyngeal, and pineal glands-Neoplasm of uncertain behavior of carotid body, aortic body, and other paraganglia Neoplasm of uncertain behavior of brain and central nervous system Neoplasm of unspecified behavior of brain Other specified disorders of thyroid Intraspinal abscess and granuloma G45.0 G45.1 G45.8 G45.9 G50.0 G50.1 G52.0-G52.9 G53 G54.0 G54.1 Vertebro-basilar artery syndrome Carotid artery syndrome (hemispheric) Other transient cerebral ischemic attacks and related syndromes Transient cerebral ischemic attack, unspecified Trigeminal neuralgia Atypical facial pain Disorders of cranial nerves Cranial nerve disorders in diseases classified elsewhere Brachial plexus disorders Lumbosacral plexus disorders C73 C79.3-C79.49 D32.0-D33.9 D44.3-D44.7 D43.0-D43.9 Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 8 of 13 G54.2 G54.3 G54.4 G80.8 G80.9 G93.5 G95.0 H71.93 H71.03 H71.13 H74.40 H71.23 H71.33 I60.9 I61.9 I62.00 I62.1 I62.9 I63.019 I63.119 I63.139 I63.20 I63.219 I63.22 I63.239 I63.30 I63.40 I63.50 I63.59 I65.09 I65.1 I65.29 I65.8 I65.9 I66.09 I66.19 I66.29 Cervical root disorders, not elsewhere classified Thoracic root disorders, not elsewhere classified Lumbosacral root disorders, not elsewhere classified Other cerebral palsy Cerebral palsy, unspecified Compression of brain Syringomyelia and syringobulbia Unspecified cholesteatoma, bilateral Cholesteatoma of attic, bilateral Cholesteatoma of tympanum, bilateral Polyp of middle ear, unspecified ear Cholesteatoma of mastoid, bilateral Diffuse cholesteatosis, bilateral Nontraumatic subarachnoid hemorrhage, unspecified Nontraumatic intracerebral hemorrhage, unspecified Nontraumatic subdural hemorrhage, unspecified Nontraumatic extradural hemorrhage Nontraumatic intracranial hemorrhage, unspecified Cerebral infarction due to thrombosis of unspecified vertebral artery Cerebral infarction due to embolism of unspecified vertebral artery Cerebral infarction due to embolism of unspecified carotid artery Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerbral arteries Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries Cerebral infarction due to thrombosis of unspecified cerebral artery Cerebral infarction due to embolism of unspecified cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery Occlusion and stenosis of unspecified vertebral artery Occlusion and stenosis of basilar artery Occlusion and stenosis of unspecified carotid artery Occlusion and stenosis of other precerebral arteries Occlusion and stenosis of unspecified precerebral artery Occlusion and stenosis of unspecified middle cerebral artery Occlusion and stenosis of unspecified anterior cerebral artery Occlusion and stenosis of unspecified posterior cerebral artery Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 9 of 13 I66.9 I67.1 I67.848 I67.5 I71.00 I71.01 I72.02 I71.03 I71.1 I71.2 I71.3 I71.4 I71.5 I71.6 I71.8 I71.9 I77.71 I77.74 M40.00 M40.10 M40.209 M40.299 M40.40 M40.50 M41.00 M41.20 M41.30 M41.40 M41.50 M41.80 M41.9 M43.8X9 M47.10 M47.12 M47.14 M47.16 M48.00-M48.08 M50.00 M51.04 M51.05 M51.06 M51.9 M96.2 Occlusion and stenosis of unspecified cerebral artery Cerebral aneurysm, nonruptured Other cerebrovascular vasospasm and vasoconstriction Moyamoya disease Dissection of unspecified site of aorta Dissection of thoracic aorta Dissection of abdominal aorta Dissection of thoracoabdominal aorta Thoracic aortic aneurysm, ruptured Thoracic aortic aneurysm, without rupture Abdominal aortic aneurysm, ruptured Abdominal aortic aneurysm, without rupture Thoracoabdominal aortic aneurysm, ruptured Thoracoabdominal aortic aneurysm, without rupture Aortic aneurysm of unspecified site, ruptured Aortic aneurysm of unspecified site, without rupture Dissection of carotid artery Dissection of vertebral artery Postural kyphosis, site unspecified Other secondary kyphosis, site unspecified Unspecified kyphosis, site unspecified Other kyphosis, site unspecified Postural lordosis, site unspecified Lordosis, unspecified, site unspecified Infantile idiopathic scoliosis, site unspecified Other idio9pathic scoliosis, site unspecified Thoracogenic scoliosis, site unspecified Neuromuscular scoliosis, site unspecified Other secondary scoliosis, site unspecified Other forms of scholiosis, site unspecified Scoliosis, unspecified Other specified deforming dorsopathies, site unspecified Other spondylosis with myelopathy, site unspecified Other spondylosis with myelopathy, cervical region Other spondylosis with myelopathy, thoracic region Other spondylosis with myelopathy, lumbar region Spinal stenosis Cervical disc disorder with myelopathy, unspecified cervical region Intervertebral disc disorders with myelopathy, thoracic region Intervertebral disc disorders with myelopathy, thoracolumbar region Intervertebral disc disorders with myelopathy, lumbar region Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder Postradiation kyphosis Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 10 of 13 M96.3 M96.4 M96.5 Q05.0 Q05.1 Q05.2 Q05.4 Q07.01 Q07.02 Q07.03 Q27.9 Q28.2 Q28.3 Q85.0-Q85.09 P11.3 P11.5 P14.0 P14.1 P14.3 S06.0X6DS06.0X6S S12.000AS12.9XXS S14.0XXAS14.9XXS S22.000AS22.089S S24.0XXAS24.9XXS S32.000AS32.059S S32.10XAS32.2XXS S34.01XAS34.01XS S34.02XAS34.03XS S34.101AS34.124S S34.131AS34.139S S34.21XAS34.9XXS S44.00XAS44.92XS Postlaminectomy kyphosis Postsurgical lordosis Postradiation scoliosis Cervical spinda bifida with hydrocephalus Thoracic spina bifida with hydrocephalus Lumbar spina bifida with hydrocephalus Unspecified spina bifida with hydrocephalus Arnold-Chiari syndrome with spina bifida Arnold-Chiari syndrome with hydrocephalus Arnold-Chiari syndrome with spina bifida and hydrocephalus Congenital malformation of peripheral vascular system, unspecified Arteriovenous malformation of cerebral vessels Other malformations of cerebral vessels Neurofibromatosis Birth injury to facial nerve Birth injury to spine and spinal cord Erb’s paralysis due to birth injury Klumpke’s paralysis due to birth injury Other brachial plexus birth injuries Concussion with loss of consciousness without return to preexisting conscious level (greater than 24 hours) Fracture of cervical vertebra and other parts of neck Injury of nerves and spinal cord at neck level Fracture of the thoracic vertebra Injury of nerves and spinal cord at thorax level Open/closed fractures of lumbar spine Open/closed fractures of sacrum and coccyx Concussion and edema of lumbar spinal cord Concussion and edema of sacral spinal cord Injuries of lumbar spine and spinal cord Injuries of sacral spine and spinal cord Injuries of nerve root of lumber, sacral, and unspecified nerves at abdomen Injuries of nerves at shoulder and upper arm level Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 11 of 13 S74.00XAS74.92.XS Injuries of sciatic verve and nerves at hip and thigh level E. Variations N/A F. Quality Audit Quality Audit monitors policy compliance and/or billing accuracy at the request of the UPMC Insurance Services Division’s Technology Assessment Committee or the Benefits Reimbursement Committee. G. Records Retention Records Retention for documents, regardless of medium, are provided within the UPMC Health System Policy for Records Retention, Management and Retirement, and as indicated in the UPMC Insurance Services Division Policy and Procedure for Records Retention. Unless otherwise mandated by Federal or State law, or unless required to be maintained for litigation purposes, any communications recorded pursuant to this Policy are maintained for a minimum of ten (10) years from the date of recording. H. References Medical Literature/Clinical Information: 1. American Academy of Neurology (AAN). Evidence-based Guideline Update: Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical Motor Evoked Potentials-Author Replies, July 16, 2012. http://www.neurology.org/content/79/3/292.full.pdf+html 2. American Society of Electroneurodiagnostic Technologists (ASET). ASET – The Neurodiagnostic Society. Position Statement: Unattended Intraoperative Neurophysiologic Monitoring, March 2012. http://www.aset.org/files/public/Unattended_Monitoring_Statement_March_2012 .pdf 3. Nuwer, M.R., Emerson, R.G. Galloway, G., Legatt, A.D., Lopez, J., Minahan, R., Yamada, T., Goodin, D.S., Armon, C., Chaudhry, V., Gronseth, G.S., & Harden, C.L., Evidence-based Guideline Update: Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical Motor Evoked Potentials-American Academy of Neurology (AAN): Neurology, February 20, 2012. http://www.neurology.org/content/78/8/585.full.pdf+html 4. American Academy of Neurology (AAN). Principles of Coding for Intraoperative Neurophysiologic Monitoring and Testing- AAN Model Medical Policy. Approved February 10, 2012. http://patients.aan.com/globals/axon/assets/9339.pdf Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 12 of 13 5. American Medical Association- House of Delegates. June 2008 - Annual Meeting. Resolution 201- Intraoperative Neurophysiologic Monitoring. Page 490.. http://www.ama-assn.org/resources/doc/hod/a08resolutions.pdf Regulatory/Government Source: 1. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) No. L27499 – Intraoperative Neurophysiological Testing. (Contractor: Novitas Solutions). Revision Effective Date: 01/01/2013. http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=27499&ContrId=165&ver=53&ContrVer=2&CntrctrSelecte d=165*2&Cntrctr=165&name=Novitas+Solutions%2c+Inc.+(12501%2c+MAC++Part+A)&s=45&DocType=All&bc=AggAAAIAAAAAAA%3d%3d& 2. National Guideline Clearinghouse- Evidence-based Guideline Update: Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical Motor Evoked Potentials, February 21, 2012. http://www.guideline.gov/content.aspx?id=36896&search=intraoperative+neurop hysiologic+monitoring Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved POLICY NUMBER: PAY.087 REVISION DATE: 12/13 ANNUAL APPROVAL DATE: 02/14 PAGE NUMBER: 13 of 13 Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not constitute medical advice and are not intended to govern or otherwise influence the practice of medicine. The policies constitute only the reimbursement and coverage guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for services varies for individual members in accordance with the terms and conditions of applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with governing regulatory agencies. UPMC Health Plan reserves the right to review and update the medical payment and prior authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall be provided in accordance with the terms and conditions of provider agreements and any applicable laws or regulations. These policies are the proprietary information of UPMC Health Plan. Any sale, copying, or dissemination of said policies is prohibited. Proprietary and Confidential Information of UPMC Health Plan © 2014 UPMC All Rights Reserved