Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)

Section: Miscellaneous
Effective Date: July 01, 2019
Revised Date: May 15, 2019
Last Reviewed: May 19, 2020

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.

Criteria

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

Links

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.