Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that intraoperative neurophysiological testing may be used to identify/prevent complications 
during surgery on the nervous system, its blood supply, or adjacent tissue. 
 
Monitoring can identify new neurologic impairment, identify, or separate nervous system structures (e.g., 
around or in a tumor), and can demonstrate which tracts or nerves are still functional. Intraoperative 
neurophysiological testing may provide relative reassurance to the surgeon that no identifiable complication 
has been detected up to a certain point, allowing the surgeon to proceed further and provide a more thorough or 
careful surgical intervention than would have been provided in the absence of monitoring. 
 
Some high-risk patients may be candidates for a surgical procedure only if monitoring is available. To establish 
medical necessity the following guidelines must be followed: 
 Intraoperative testing may be indicated with the following types of surgery: 
1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including internal carotid artery surgery, 
when there is risk of cerebral ischemia 
2. Resection of epileptogenic brain tissue or tumor 
3. Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
4. Protection of cranial nerves: 
a. tumors that are optic, trigeminal, facial, auditory nerves 
b. cavernous sinus tumors 
c. oval or round window graft 
d. endolymphatic shunt for Meniere's disease 
e. vestibular section for vertigo 
f. microvascular decompression of cranial nerves 
5. Correction of scoliosis or deformity of spinal cord involving traction on the cord 
6. Protection of spinal cord where work is performed in close proximity to cord as in the removal of old 
hardware or where there have been numerous interventions 
7. Spinal instrumentation requiring pedicle screws or distraction 8. Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or 
claudication where function of spinal cord or spinal nerves is at risk 
9. Resection of: 
a. Spinal cord tumors 
b. Neuromas of peripheral nerves or brachial plexus, when there is risk to major sensory or motor 
nerves 
10. Surgery for: 
a. intracranial AV malformations 
b. arteriovenous malformation of spinal cord 
c. surgery for intractable movement disorders 
d. cerebral vascular aneurysms 
11. Arteriography, during which there is a test occlusion of the carotid artery 
12. Circulatory arrest with hypothermia 
13. Distal aortic procedures, where there is risk of ischemia to spinal cord 
14. Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
15. Basil ganglia movement disorders 
16. Surgery as a result of traumatic injury to spinal cord/brain 
17. Deep brain stimulation 
Limitations 
For reimbursement, this test must be requested by the operating surgeon and the monitoring must be performed 
by a physician, other than: 
 The operating surgeon 
 The technical/surgical assistant; or 
 The anesthesiologist rendering the anesthesia 
The benefits of intraoperative neurophysiologic testing are attainable under optimal recording and interpreting 
conditions. 
 
Due to the nature of these services and the potential for significant morbidity in some procedures requiring 
intraoperative monitoring, Medicare expects to see these services used in the hospital setting only. As the level 
of anesthesia may significantly impact the ability to interpret intraoperative studies, continuous communication 
between the anesthesiologist and the monitoring physician is expected when medically indicated. 
 
It is also expected that a specifically trained technician, preferably registered with one of the credentialing 
organizations, will be in continuous attendance in the operating room, recording and monitoring a single 
surgical case, with either the physical or electronic capacity for real-time communication with the supervising 
neurologist or other physician trained in neurophysiology. 
 
Intraoperative monitoring is not medically necessary in situations where historical data and current practices 
reveal no potential for damage to neural integrity during surgery. Monitoring under these circumstances will 
exceed the patient's medical need. 
 
Due to the potential risk for morbidity with many of the above noted surgeries and the need for explicit and 
focused attention to both the monitoring and the procedure, Medicare does not expect to see operating surgeons 
submitting claims for this code. Monitoring may be performed from a remote site, as long as a trained 
technician (see detail above) will be in continuous attendance in the operating room, with either the physical or 
electronic capacity for real-time communication with the supervising physician (MD/DO). Technical criteria 
(mandatory) include that at least 8 recording channels be available (16 if EEG is monitored) for all 
intraoperative neurophysiological monitoring. The remotely supervising physician 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. 
 
Technical criteria (mandatory) for remote monitoring also include (a) routine real-time auditory or written 
communication between the supervising physician and the operating room and (b) the capability for telephone 
communications as needed between the supervising physician and the monitoring technologist, operating 
surgeon, and the anesthesiologist. 
 
The equipment must also provide for all of the monitoring modalities that may be applied - auditory-evoked 
response, electroencephalography/electrocorticography, electromyography and nerve conduction, and 
somatosensory-evoked response. 
 
Undivided attention to a unique patient may be required during some surgeries, such as during response to 
acute events or identification of the cerebral cortex to be resected or spared from resection. The monitoring 
physician must have a plan in place to transfer care to another physician of any other case during those times. 
When paying undivided attention to a unique patient, the physician must code and bill only for that one case 
during those times. For other medically necessary intraoperative neurophysiologic monitoring, a physician may 
monitor up to three cases simultaneously. 
 
Medicare does not provide for reimbursement of "incident to" care in the hospital setting. More than one 
patient may be monitored at once; however, claims for physician services must be submitted only for the time 
devoted to monitoring when attention is directed exclusively to one patient. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L34623: Intraoperative 
Neurophysiological Testing. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.