Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar radicular pain of the right lower extremity.

Treatment: Current procedural terminology (CPT) codes 95938-26 short latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs, 95870-26 x (times) 2, needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters and 95941 continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (list separately in addition to code for primary procedure) with diagnosis code M51.17.

The insurer denied coverage for current procedural terminology (CPT) codes 95938-26 short latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs, 95870-26 x 2, needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters and 95941 continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (list separately in addition to code for primary procedure) with diagnosis code M51.17.

The denial is upheld.

The patient is a male with a history of lumbar radiculopathy. He underwent an L (lumbar)5-S (sacral)1 laminectomy microdiscectomy with use of intraoperative neurophysiologic monitoring that included somatosensory evoked potential (SSEP), electromyography (EMG) and train of four.

Hadley, et al states, "Electrophysiological monitoring techniques allow the assessment of spinal cord sensory pathways, motor pathways (MEPs), and spinal root function (electromyographic potentials). Recording of these parameters after spinal cord injury or during spinal column or spinal cord operative procedures (IOM) has the potential to evaluate the integrity of the sensory and motor pathways and spinal roots in real-time fashion (diagnostic potential). Theoretically, alterations in established recordings during spinal cord/spinal column surgery implicate an impending spinal cord injury-an injury that could potentially be prevented (risk factors for injury reversed or corrected) to help assure a better outcome following surgery (therapeutic potential). A great deal has been written on the topic of electrophysiological monitoring and spinal cord function. Despite the use of phrases such as "standard of care" by some authors and professional medical subspecialty organizations, significant clinical equipoise exists, and the value of IOM during spinal surgery remains controversial." (1)

Daniel, et al states, "IONM (intraoperative neurophysiological monitoring) did not result into fewer neurological events with the obtained evidence of the included studies. For intramedullary lesions, there was a trend to fewer neurological events in patients who underwent surgery with IONM. Further prospective randomized studies are necessary to clarify the indications of IONM in spinal surgeries." (2)

The use of intraoperative neurophysiologic monitoring during a simple, noncomplex surgery is not standard of care and has not proven to be effective in preventing injury during surgery. The CPT codes requested are not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Intraoperative monitoring is not standard of care for an L5-S1 laminectomy with microdiscectomy.

The insurer's denial of coverage for current procedural terminology (CPT) codes 95938-26 short latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs, 95870-26 x 2, needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters and 95941 continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (list separately in addition to code for primary procedure) with diagnosis code M51.17, is upheld. Medical Necessity is not substantiated.