Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)

Policy ID: G-48-003

Section: Miscellaneous

Effective Date: July 01, 2019

Revised Date: April 19, 2021

Revision Effective Date: July 01, 2021

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Cerebral oxygenation monitoring utilizes near-infrared spectroscopy (NIRS) a non-invasive technology capable of continuously obtaining data related to cerebral blood flow and specifically hemoglobin oxygen saturation. This data is used to estimate the oxygen O₂ saturation of the cerebral tissue.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS) is considered experimental/investigational, as published data are inadequate to prove the safety and efficacy of this procedure.

Procedure Codes

94799

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: G-48-002

Section: Miscellaneous

Effective Date: July 01, 2019

Revised Date: April 19, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: May 20, 2021

Archived Date: July 04, 2021

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Procedure Codes

94799

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review

Links

References (PDF)

Disclaimer

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